MEDICARE: PREFERRED IMAGING OF FORT WORTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2085R0202X	Diagnostic Radiology Physician
2	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center
3	261QR0200X	Radiology Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043566011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREFERRED IMAGING OF FORT WORTH LLC

Provider Business Mailing Address
First Line	:	P O BOX 674328
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267-4328
Country	:	US
Telephone Number	:	469-362-6909
Fax Number	:	214-494-4295

Provider Business Practice Location Address
First Line	:	851 GRAINGER ST
Second Line	:	SUITE 101
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4645
Country	:	US
Telephone Number	:	469-362-6909
Fax Number	:	214-494-4295

Authorized Official
Title or Position	:	SR VICE PRESIDENT
Name	:	LAURA KASSA
Credential	:
Telephone Number	:	904-515-0362

Provider Enumeration Date	:	07/27/2012
Last Update Date	:	04/06/2022

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