=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245817386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIG SPRING RADIOLOGY ASSOCIATES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2021
-----------------------------------------------------
Last Update Date | 03/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 W 11TH PL
-----------------------------------------------------
City | BIG SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79720-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-263-1211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1415 NORTH LOOP W STE 240
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77008-1677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-426-9102
-----------------------------------------------------
Fax | 713-426-4015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | MARIO J CASTILLO
-----------------------------------------------------
Credential | M.D., PH.D.
-----------------------------------------------------
Telephone | 713-426-9102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------