1811932577 NPI number — TENET GULF COAST IMAGING

Table of content: (NPI 1811932577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811932577 NPI number — TENET GULF COAST IMAGING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENET GULF COAST IMAGING
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:
CEDAR LAKE IMAGING CENTER
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:
1811932577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 676764
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75267-6764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-396-1601
Provider Business Mailing Address Fax Number:
228-392-9620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
975A CEDAR LAKE RD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
BILOXI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39532-2128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-395-1601
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BURTNETT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
KYLE
Authorized Official Title or Position:
VSVP OF OUTPATIENT SERVICES, TENET
Authorized Official Telephone Number:
469-893-2153

Provider Taxonomy Codes

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

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





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