1942209515 NPI number — NORTHWEST DIAGNOSTIC CLINIC, PA

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 1942209515 NPI number — NORTHWEST DIAGNOSTIC CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST DIAGNOSTIC CLINIC, 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:
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:
1942209515
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2255 E MOSSY OAKS RD STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77389-1813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-440-5300
Provider Business Mailing Address Fax Number:
832-232-5591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8845 SIX PINES DR FL 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHENANDOAH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77380-2675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-232-5500
Provider Business Practice Location Address Fax Number:
832-232-5510
Provider Enumeration Date:
07/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FILLMAN
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
832-232-5500

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , 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)

  • Identifier: 162607901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00T359 . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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