=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750626628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MVP BURLESON LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2012
-----------------------------------------------------
Last Update Date | 09/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 649 NE ALSBURY BLVD STE 101
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-2660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-886-8919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 BAILEY AVE STE 750
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-2175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR DIR OF REV CYCLE MGMT
-----------------------------------------------------
Name | APRIL SAWYER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-202-5179
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------