MEDICARE: STAR DIAGNOSTICS OF TARRANT COUNTY

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	293D00000X	Physiological Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8V5961	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1679525695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STAR DIAGNOSTICS OF TARRANT COUNTY

Provider Business Mailing Address
First Line	:	PO BOX 226656
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75222-6656
Country	:	US
Telephone Number	:	214-943-9431
Fax Number	:	214-943-9407

Provider Business Practice Location Address
First Line	:	2100 N MAIN ST
Second Line	:	LL20
City	:	FORT WORTH
State	:	TX
Zip	:	76106-8570
Country	:	US
Telephone Number	:	214-943-9431
Fax Number	:	214-943-9407

Authorized Official
Title or Position	:	ADMINSTRATOR
Name	:	LINDA L RILEY
Credential	:
Telephone Number	:	214-943-9431

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	01/23/2008

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Directions to “STAR DIAGNOSTICS OF TARRANT COUNTY ” Practice Location

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