=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881649622
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAYTEL NUCLEAR IMAGING - WEST HOUSTON, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 08/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1416 CAMPBELL RD SUITE 101
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77055-4604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-464-7914
-----------------------------------------------------
Fax | 713-464-8270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 WATERSIDE XING 3RD FLOOR ATTN: KAREN FRISK, CONTRACTING
-----------------------------------------------------
City | WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06095-1540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-367-1095
-----------------------------------------------------
Fax | 860-298-6127
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JEFFREY M FLANEGIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-831-1112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | L04882
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------