Basic Information
| Provider Information | |||||||||
| NPI: | 1083990717 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXAS RADIOLOGY ASSOCIATES LLP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2285 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462062285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664379810 | ||||||||
| FaxNumber: | 4697571095 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 ENA RD | ||||||||
| Address2: | 200 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968151779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728677862 | ||||||||
| FaxNumber: | 9726121623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2011 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEN | ||||||||
| AuthorizedOfficialFirstName: | TED | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9728677862 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | DC0892 | 01 | TX | RR MEDICARE | OTHER | 081568002 | 05 | TX | MEDICAID | 009767 | 01 | TX | BCBS | OTHER | 218812001 | 05 | TX | MEDICAID | 081568001 | 05 | TX | MEDICAID |