MEDICARE: PMG ULTRASOUND

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	207VM0101X	Maternal & Fetal Medicine Physician
2	261QR0208X	Mobile Radiology Clinic/Center

General Provider Information

NPI Number	:	1356154199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PMG ULTRASOUND

Provider Business Mailing Address
First Line	:	1410 CHANTILLY LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-4131
Country	:	US
Telephone Number	:	832-978-5611
Fax Number	:

Provider Business Practice Location Address
First Line	:	1410 CHANTILLY LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-4131
Country	:	US
Telephone Number	:	832-978-5611
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	GABRIEL IANCULOVICI
Credential	:	COO
Telephone Number	:	832-978-5611

Provider Enumeration Date	:	01/27/2025
Last Update Date	:	01/28/2025

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Directions to “PMG ULTRASOUND ” Practice Location

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