1407980030 NPI number — MED TEL INTERNATIONAL CORPORATION

Table of content: (NPI 1407980030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407980030 NPI number — MED TEL INTERNATIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED TEL INTERNATIONAL CORPORATION
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:
WIDE OPEN MRI
Provider Other Organization Name Type Code:
3
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:
1407980030
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1430 SPRING HILL RD
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
MCLEAN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22102-3000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-287-4189
Provider Business Mailing Address Fax Number:
703-448-1807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1321 W 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORSICANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75110-3775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-875-0606
Provider Business Practice Location Address Fax Number:
903-875-0303
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VALLA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
973-873-9850

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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