1912989120 NPI number — MEMORIAL MRI AND DIAGNOSTIC LLC

Table of content: (NPI 1912989120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912989120 NPI number — MEMORIAL MRI AND DIAGNOSTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMORIAL MRI AND DIAGNOSTIC LLC
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:
1912989120
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 802185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77280-2185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-461-3399
Provider Business Mailing Address Fax Number:
713-463-5996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1346 CAMPBELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77055-6404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-461-3399
Provider Business Practice Location Address Fax Number:
713-463-5996
Provider Enumeration Date:
11/15/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TRAN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
713-461-3399

Provider Taxonomy Codes

  • Taxonomy code: 2085B0100X , with the licence number:  R26701 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X , with the licence number: R26701 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: R26701 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0203X , with the licence number: R26701 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: R26701 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X , with the licence number: R26701 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0203DC . This is a "BLUE CROSS PROVIDER#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1539850-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 153985002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".