1497012231 NPI number — MODERN RADIOLOGY ASSOCIATES, PLLC

Table of content: (NPI 1497012231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497012231 NPI number — MODERN RADIOLOGY ASSOCIATES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN RADIOLOGY ASSOCIATES, PLLC
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:
1497012231
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 WATERWAY AVE
Provider Second Line Business Mailing Address:
SUITE 1303
Provider Business Mailing Address City Name:
THE WOODLANDS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77380-3449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-818-7481
Provider Business Mailing Address Fax Number:
832-442-5377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 WATERWAY AVE
Provider Second Line Business Practice Location Address:
SUITE 1303
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77380-3449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-818-7481
Provider Business Practice Location Address Fax Number:
832-442-5377
Provider Enumeration Date:
04/18/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PORTER
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
PRESIDENT/RADIOLOGIST
Authorized Official Telephone Number:
713-818-7481

Provider Taxonomy Codes

  • Taxonomy code: 2085N0700X , with the licence number:  P1211 , 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: P1211 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X , with the licence number: P1211 , 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)