Basic Information
| Provider Information | |||||||||
| NPI: | 1497012231 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MODERN RADIOLOGY ASSOCIATES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WATERWAY AVE | ||||||||
| Address2: | SUITE 1303 | ||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773803449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138187481 | ||||||||
| FaxNumber: | 8324425377 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WATERWAY AVE | ||||||||
| Address2: | SUITE 1303 | ||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773803449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138187481 | ||||||||
| FaxNumber: | 8324425377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2012 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | PORTER | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/RADIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7138187481 | ||||||||
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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 | 2085R0204X | P1211 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085N0700X | P1211 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | P1211 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.