Basic Information
| Provider Information | |||||||||
| NPI: | 1861782740 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY ASSOCIATES OF NORTH TEXAS, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RADIOLOGY ASSOCIATES OF TARRANT COUNTY PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 816 W CANNON ST | ||||||||
| Address2: | CREDENTIALING 1861782740 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210387 | ||||||||
| FaxNumber: | 4695226889 | ||||||||
| Practice Location | |||||||||
| Address1: | 816 W CANNON ST | ||||||||
| Address2: | CREDENTIALING 1861782740 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210387 | ||||||||
| FaxNumber: | 4695226889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 06/20/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHELPS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8173210312 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 121715004 | 05 | TX | MEDICAID | 121715005 | 05 | TX | MEDICAID | 121715009 | 05 | TX | MEDICAID | 1407146387 | 01 | TX | NPI | OTHER | 285250104 | 05 | TX | MEDICAID | 1861782740 | 01 | TX | NPI | OTHER | 121715008 | 05 | TX | MEDICAID | 285250105 | 05 | TX | MEDICAID |