Healthcare Provider Details

I. General information

NPI: 1942424452
Provider Name (Legal Business Name): GED MEDICAL MANAGEMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 COOPER STREET
FORT WORTH TX
76104
US

IV. Provider business mailing address

2001 COOPER STREET
FORT WORTH TX
76104
US

V. Phone/Fax

Practice location:
  • Phone: 817-877-3054
  • Fax: 817-546-0851
Mailing address:
  • Phone: 817-877-3054
  • Fax: 817-546-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberR29901
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALAN IRA ETTINGER
Title or Position: CFO/PRESIDENT
Credential: DPM
Phone: 817-877-3054