Basic Information
Provider Information | |||||||||
NPI: | 1558431619 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FW IMAGING | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4400 OAK PARK LANE | ||||||||
Address2: | STE 101 | ||||||||
City: | FT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 76109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8172079600 | ||||||||
FaxNumber: | 8172079692 | ||||||||
Practice Location | |||||||||
Address1: | 4400 OAK PARK LANE | ||||||||
Address2: | STE 101 | ||||||||
City: | FT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 76109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8172079600 | ||||||||
FaxNumber: | 8172079692 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2006 | ||||||||
LastUpdateDate: | 02/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DILLON | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 8172079600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
ID | Type | State | Issuer | Description | P00289429 | 01 | TX | MEDICARE RAILROAD | OTHER |