1588661144 NPI number — WOMEN'S IMAGING AND WELLNESS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588661144 NPI number — WOMEN'S IMAGING AND WELLNESS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOMEN'S IMAGING AND WELLNESS, INC.
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:
1588661144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15601 DALLAS PARKWAY
Provider Second Line Business Mailing Address:
STE. 500
Provider Business Mailing Address City Name:
ADDISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75001-6021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-398-4110
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5156 BLAZER PKWY
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43017-7318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-791-9355
Provider Business Practice Location Address Fax Number:
614-791-2970
Provider Enumeration Date:
06/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
POLFREMAN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
469-398-4110

Provider Taxonomy Codes

  • Taxonomy code: 261QR0206X , with the licence number:  03-G-02046-01 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101212 . This is a "MAMMOGRAPHY CERTIFICATION" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2817241 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000299853 . This is a "ANTHEM PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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