MEDICARE: SOUTH LOOP MRI LP

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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1922104850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH LOOP MRI LP

Provider Business Mailing Address
First Line	:	PO BOX 2569
Second Line	:
City	:	STAFFORD
State	:	TX
Zip	:	77497-2569
Country	:	US
Telephone Number	:	713-664-1330
Fax Number	:	713-592-6772

Provider Business Practice Location Address
First Line	:	2616 S LOOP W
Second Line	:	SUITE 170
City	:	HOUSTON
State	:	TX
Zip	:	77054-2662
Country	:	US
Telephone Number	:	713-665-6767
Fax Number	:	713-664-0327

Authorized Official
Title or Position	:	DIRECTOR OF MANAGED CARE
Name	:	DEBBIE ROSS
Credential	:
Telephone Number	:	281-772-7749

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	10/03/2012

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