=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740228097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOUSTON RADIOLOGY ASSOCIATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 05/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6565 FANNIN
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77030-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-441-7558
-----------------------------------------------------
Fax | 713-793-1594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2190 NORTH LOOP WEST SUITE 250
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77018-8016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-206-9020
-----------------------------------------------------
Fax | 281-206-9018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JETT R BRADY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 713-441-7558
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------