MEDICARE: USMD DIAGNOSTIC SERVICES, LLC

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1780940270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	USMD DIAGNOSTIC SERVICES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 678168
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267-8168
Country	:	US
Telephone Number	:	972-847-0712
Fax Number	:	817-514-5246

Provider Business Practice Location Address
First Line	:	6333 NORTH STATE HIGHWAY 161
Second Line	:	SUITE 200
City	:	IRVING
State	:	TX
Zip	:	75038-4049
Country	:	US
Telephone Number	:	817-514-5200
Fax Number	:	817-514-5210

Authorized Official
Title or Position	:	PRESIDENT PPM
Name	:	MICHAEL W BUKOSKY
Credential	:
Telephone Number	:	972-847-0712

Provider Enumeration Date	:	04/09/2012
Last Update Date	:	11/08/2016

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