MEDICARE: MICHAEL JAMES BLACKSHEAR R.T.

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	247100000X	Radiologic Technologist

General Provider Information

NPI Number	:	1366558868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL JAMES BLACKSHEAR R.T.

Provider Business Mailing Address
First Line	:	2138 STONEY BROOK DR
Second Line	:
City	:	DEER PARK
State	:	TX
Zip	:	77536-4600
Country	:	US
Telephone Number	:	713-791-1414
Fax Number	:

Provider Business Practice Location Address
First Line	:	2138 STONEY BROOK DR
Second Line	:
City	:	DEER PARK
State	:	TX
Zip	:	77536-4600
Country	:	US
Telephone Number	:	713-791-1414
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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