1245236132 NPI number — LUBBOCK RADIOLOGY LP

Table of content: (NPI 1245236132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245236132 NPI number — LUBBOCK RADIOLOGY LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUBBOCK RADIOLOGY LP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245236132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79408-2160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-792-2767
Provider Business Mailing Address Fax Number:
806-791-6709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3707 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79410-1219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-792-2767
Provider Business Practice Location Address Fax Number:
806-791-6709
Provider Enumeration Date:
06/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MEDANICH
Authorized Official First Name:
MONTY
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
806-792-2767

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 293D00000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 293D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1895212 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 470001572 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: J730 . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: W6027 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104497100 . This is a "FIRSTCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 153651801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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