MEDICARE: TIDC-IRVING, INC

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	2085R0202X	Diagnostic Radiology Physician	R22410	TX

General Provider Information

NPI Number	:	1154385102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDC-IRVING, INC

Provider Business Mailing Address
First Line	:	3636 N MACARTHUR BLVD
Second Line	:	SUITE 170
City	:	IRVING
State	:	TX
Zip	:	75062-3637
Country	:	US
Telephone Number	:	972-255-9444
Fax Number	:	972-570-4664

Provider Business Practice Location Address
First Line	:	3636 N MACARTHUR BLVD
Second Line	:	SUITE 170
City	:	IRVING
State	:	TX
Zip	:	75062-3637
Country	:	US
Telephone Number	:	972-255-9444
Fax Number	:	972-570-4664

Authorized Official
Title or Position	:	CEO
Name	:	EMIL GEORGIO CERULLO
Credential	:
Telephone Number	:	214-357-5229

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	07/30/2007

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