1003092883 NPI number — ADVANTECHS X-RAY IMAGING SERVICES, LLC

Table of content: (NPI 1003092883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003092883 NPI number — ADVANTECHS X-RAY IMAGING SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTECHS X-RAY IMAGING SERVICES, 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:
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:
1003092883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 639295 DEPT 93410
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-9295
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-759-7291
Provider Business Mailing Address Fax Number:
855-618-6655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4545 FULLER DR
Provider Second Line Business Practice Location Address:
STE. 325
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75038-6530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-759-7291
Provider Business Practice Location Address Fax Number:
248-824-0630
Provider Enumeration Date:
01/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
STEVENS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-824-6000

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X , with the licence number:  R28054 , 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: 163031101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 459891 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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