=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790714087
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOMBALL IMAGING, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2006
-----------------------------------------------------
Last Update Date | 10/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24727 TOMBALL PARKWAY SUITE 110
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-516-0660
-----------------------------------------------------
Fax | 281-440-2020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24727 TOMBALL PARKWAY SUITE 110
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-516-0660
-----------------------------------------------------
Fax | 281-440-2020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTRACT ADMINISTRATOR
-----------------------------------------------------
Name | STEPHANIE L TROCKO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-453-7917
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------