MEDICARE: FW IMAGING

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	261QR0200X	Radiology Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00289429	OTHER	TX	MEDICARE RAILROAD

General Provider Information

NPI Number	:	1558431619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FW IMAGING

Provider Business Mailing Address
First Line	:	4400 OAK PARK LANE
Second Line	:	STE 101
City	:	FT WORTH
State	:	TX
Zip	:	76109
Country	:	US
Telephone Number	:	817-207-9600
Fax Number	:	817-207-9692

Provider Business Practice Location Address
First Line	:	4400 OAK PARK LANE
Second Line	:	STE 101
City	:	FT WORTH
State	:	TX
Zip	:	76109
Country	:	US
Telephone Number	:	817-207-9600
Fax Number	:	817-207-9692

Authorized Official
Title or Position	:	COO
Name	:	CHARLES W DILLON
Credential	:
Telephone Number	:	817-207-9600

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	02/20/2008

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Directions to “FW IMAGING ” Practice Location

Language	Start Address	Practice Location

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