Basic Information
| Provider Information | |||||||||
| NPI: | 1871788224 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAMIC FORT WORTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 12TH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177635900 | ||||||||
| FaxNumber: | 8177635858 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 12TH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177635900 | ||||||||
| FaxNumber: | 8177635858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | VIG | ||||||||
| AuthorizedOfficialFirstName: | ROCKY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2144372309 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FEG, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 195662501 | 05 | TX | MEDICAID |