MEDICARE: THE HEART DOCTOR IMAGING CENTER

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	261QM2500X	Medical Specialty Clinic/Center		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HH1822	OTHER	TX	BCBS FACILITY ID

General Provider Information

NPI Number	:	1770696007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE HEART DOCTOR IMAGING CENTER

Provider Business Mailing Address
First Line	:	5124 NORTH ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1368
Country	:	US
Telephone Number	:	936-564-2828
Fax Number	:	936-569-1956

Provider Business Practice Location Address
First Line	:	5124 NORTH ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1368
Country	:	US
Telephone Number	:	936-564-2828
Fax Number	:	936-569-1956

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	LISA G YOUNG
Credential	:	RN
Telephone Number	:	936-564-2828

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	08/22/2020

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Directions to “THE HEART DOCTOR IMAGING CENTER ” Practice Location

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