1366423790 NPI number — CONROE TOMBALL RADIOLOGISTS PA

Table of content: (NPI 1366423790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366423790 NPI number — CONROE TOMBALL RADIOLOGISTS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONROE TOMBALL RADIOLOGISTS PA
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:
6
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:
1366423790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 ROCKMEAD DR
Provider Second Line Business Mailing Address:
S:210
Provider Business Mailing Address City Name:
KINGWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77339-2112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-359-7788
Provider Business Mailing Address Fax Number:
281-359-7888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9250 PINECROFT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-359-7788
Provider Business Practice Location Address Fax Number:
281-359-7888
Provider Enumeration Date:
11/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BALSARA
Authorized Official First Name:
VIREN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
281-359-7788

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 127270003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 127270001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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