=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356361851
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENNIS RADIOLOGY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 07/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 W 11TH PL
-----------------------------------------------------
City | BIG SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79720-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-992-0875
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13320 GRAYHAWK BLVD
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75034-1698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | AUNG THEIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 972-992-0875
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | K4814
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------