MEDICARE: DIAGNOSTIC CLINIC OF LONGVIEW PA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	207RS0012X	Sleep Medicine (Internal Medicine) Physician	TX
3	207RG0100X	Gastroenterology Physician	TX
4	207Q00000X	Family Medicine Physician	TX
5	207RI0011X	Interventional Cardiology Physician
6	207RI0200X	Infectious Disease Physician	TX
7	207V00000X	Obstetrics & Gynecology Physician
8	207X00000X	Orthopaedic Surgery Physician
9	207Y00000X	Otolaryngology Physician
10	208000000X	Pediatrics Physician
11	2084N0400X	Neurology Physician
12	208600000X	Surgery Physician
13	207UN0901X	Nuclear Cardiology Physician
14	213ES0103X	Foot & Ankle Surgery Podiatrist
15	207R00000X	Internal Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	45D0482673	OTHER	TX	DME RR MEDICARE

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386638468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIAGNOSTIC CLINIC OF LONGVIEW PA

Provider Business Mailing Address
First Line	:	707 HOLLYBROOK DR
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75605-2410
Country	:	US
Telephone Number	:	903-757-6042
Fax Number	:	903-232-8226

Provider Business Practice Location Address
First Line	:	707 HOLLYBROOK DR
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75605-2410
Country	:	US
Telephone Number	:	903-757-6042
Fax Number	:	903-232-8226

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MS. DORA C REEVES
Credential	:
Telephone Number	:	903-291-6062

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	02/05/2009

Similar Medicare Providers

1730186172 — PHILIP P HAWNER M.D.
Practice Location Address:

707 HOLLYBROOK DR , SUITE 400
LONGVIEW, TX
75605-2410

Practice Phone: 903-230-3223
Practice Fax: 903-753-7420

1245226349 — DR. CARLTON E. HARDIN II MD
Practice Location Address:

707 HOLLYBROOK DR
LONGVIEW, TX
75605-2410

Practice Phone: 903-757-6042
Practice Fax: 903-232-8226

1730170309 — VICTOR D KENNEL PT
Practice Location Address:

707 HOLLYBROOK DR , SUITE 500
LONGVIEW, TX
75605-2410

Practice Phone: 903-291-6113
Practice Fax: 903-234-9126

1811974223 — DR. DONNA DAVIS MD
Practice Location Address:

707 HOLLYBROOK DR
LONGVIEW, TX
75605-2410

Practice Phone: 903-757-6042
Practice Fax: 903-232-8298

1336116169 — DR. JOHN T D'ANTONI MD
Practice Location Address:

707 HOLLYBROOK DR
LONGVIEW, TX
75605-2410

Practice Phone: 903-757-6042
Practice Fax: 903-232-8226

1699742338 — DR. GREGORY E HERBECK MD
Practice Location Address:

707 HOLLYBROOK DR
LONGVIEW, TX
75605-2410

Practice Phone: 903-757-6042
Practice Fax: 903-232-8556

Directions to “DIAGNOSTIC CLINIC OF LONGVIEW PA ” Practice Location

Language	Start Address	Practice Location

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