Healthcare Provider Details

I. General information

NPI: 1891755468
Provider Name (Legal Business Name): WACO RADIOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 LONDONDERRY DR STE 104
WACO TX
76712-7924
US

IV. Provider business mailing address

PO BOX 103
ROCKWALL TX
75087-0103
US

V. Phone/Fax

Practice location:
  • Phone: 469-757-1000
  • Fax:
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 MANGER
Credential:
Phone: 405-321-8125