1588661144 NPI number — WOMEN'S IMAGING AND WELLNESS, INC.

Table of content: (NPI 1588661144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588661144 NPI number — WOMEN'S IMAGING AND WELLNESS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOMEN'S IMAGING AND WELLNESS, INC.
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:
1588661144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15601 DALLAS PARKWAY
Provider Second Line Business Mailing Address:
STE. 500
Provider Business Mailing Address City Name:
ADDISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75001-6021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-398-4110
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5156 BLAZER PKWY
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43017-7318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-791-9355
Provider Business Practice Location Address Fax Number:
614-791-2970
Provider Enumeration Date:
06/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
POLFREMAN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
469-398-4110

Provider Taxonomy Codes

  • Taxonomy code: 261QR0206X , with the licence number:  03-G-02046-01 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101212 . This is a "MAMMOGRAPHY CERTIFICATION" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2817241 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000299853 . This is a "ANTHEM PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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