Basic Information
| Provider Information | |||||||||
| NPI: | 1417062654 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS NEURORADIOLOGY, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8440 WALNUT HILL LN STE 510 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752313835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143454441 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8440 WALNUT HILL LN | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752313833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143454406 | ||||||||
| FaxNumber: | 2143455543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 08/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | KORTE | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2143454441 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 083687601 | 05 | TX | MEDICAID |