Basic Information
| Provider Information | |||||||||
| NPI: | 1982680542 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY UNLIMITED, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3432 | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779033432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615763680 | ||||||||
| FaxNumber: | 3615764219 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 N VIRGINIA ST | ||||||||
| Address2: | |||||||||
| City: | PORT LAVACA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779793025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615763680 | ||||||||
| FaxNumber: | 3615764219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MALEK | ||||||||
| AuthorizedOfficialFirstName: | GHOLAMREZA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3615763680 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | K9841 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0077HS | 01 | TX | BCBS OF TX # | OTHER |