Basic Information
| Provider Information | |||||||||
| NPI: | 1740228097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOUSTON RADIOLOGY ASSOCIATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2190 NORTH LOOP WEST | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770188016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812069020 | ||||||||
| FaxNumber: | 2812069018 | ||||||||
| Practice Location | |||||||||
| Address1: | 6565 FANNIN | ||||||||
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| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134417558 | ||||||||
| FaxNumber: | 7137931594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 05/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | BRADY | ||||||||
| AuthorizedOfficialFirstName: | JETT | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7134417558 | ||||||||
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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 | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 112542901 | 05 | TX | MEDICAID |