Basic Information
| Provider Information | |||||||||
| NPI: | 1437117181 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAVERICK COUNTY RURAL RADIOLOGISTS P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1888 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754031888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005933216 | ||||||||
| FaxNumber: | 9034532541 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 N FOSTER MALDONADO BLVD | ||||||||
| Address2: | |||||||||
| City: | EAGLE PASS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788525893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8307735321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | HNATOW-PARIS | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8307575080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 081212501 | 05 | TX | MEDICAID |