Healthcare Provider Details

I. General information

NPI: 1578674974
Provider Name (Legal Business Name): MCH PROFESSIONAL CARE RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W 4TH ST
ODESSA TX
79761-5001
US

IV. Provider business mailing address

PO BOX 704
INDIANAPOLIS IN
46206-0704
US

V. Phone/Fax

Practice location:
  • Phone: 432-640-2401
  • Fax: 432-640-1031
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PHILIP MALONE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 405-321-8125