MEDICARE: NEURO IR OF EAST TEXAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085N0700X	Neuroradiology Physician

General Provider Information

NPI Number	:	1508376716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEURO IR OF EAST TEXAS

Provider Business Mailing Address
First Line	:	700 OLYMPIC PLAZA CIR STE 910
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-1915
Country	:	US
Telephone Number	:	903-705-0072
Fax Number	:	903-705-0068

Provider Business Practice Location Address
First Line	:	700 OLYMPIC PLAZA CIR STE 910
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-1915
Country	:	US
Telephone Number	:	903-705-0072
Fax Number	:	903-705-0068

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MICHELLE BLACK
Credential	:
Telephone Number	:	903-705-0072

Provider Enumeration Date	:	10/03/2017
Last Update Date	:	11/04/2023

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Directions to “NEURO IR OF EAST TEXAS ” Practice Location

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