=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942209515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST DIAGNOSTIC CLINIC, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8845 SIX PINES DR FL 2
-----------------------------------------------------
City | SHENANDOAH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77380-2675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-232-5500
-----------------------------------------------------
Fax | 832-232-5510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2255 E MOSSY OAKS RD STE 500
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77389-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-440-5300
-----------------------------------------------------
Fax | 832-232-5591
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | STEPHEN D FILLMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 832-232-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------