MEDICARE: NORTHWEST IMAGING CENTER, LTD.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1053566281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST IMAGING CENTER, LTD.

Provider Business Mailing Address
First Line	:	4185 TECHNOLOGY FOREST BLVD
Second Line	:	SUTIE 120
City	:	THE WOODLANDS
State	:	TX
Zip	:	77381-2006
Country	:	US
Telephone Number	:	281-296-9532
Fax Number	:	291-296-9774

Provider Business Practice Location Address
First Line	:	4185 TECHNOLOGY FOREST BLVD
Second Line	:	SUITE 100
City	:	THE WOODLANDS
State	:	TX
Zip	:	77381-2006
Country	:	US
Telephone Number	:	281-296-9532
Fax Number	:	291-296-9774

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. DONNA K KOTSIOS
Credential	:
Telephone Number	:	281-296-9562

Provider Enumeration Date	:	12/02/2008
Last Update Date	:	05/15/2013

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