Basic Information
| Provider Information | |||||||||
| NPI: | 1407964539 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TEXAS HEART & VASCULAR IMAGING LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 GASLIGHT BLVD | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759043133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366328787 | ||||||||
| FaxNumber: | 9366328832 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 GASLIGHT BLVD | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759043133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366328787 | ||||||||
| FaxNumber: | 9366328832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | BACHIREDDY | ||||||||
| AuthorizedOfficialFirstName: | RAVINDER | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9366328787 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 293D00000X | N | Laboratories | Physiological Laboratory | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 048374502 | 05 | TX | MEDICAID | HH1819 | 01 | TX | BLUECROSS BLUESHIELD OF TEXAS | OTHER |