MEDICARE: ADVANCED MAXILLOFACIAL IMAGING OF MCALLEN 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	2085R0202X	Diagnostic Radiology Physician	12405	TX

General Provider Information

NPI Number	:	1932499662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED MAXILLOFACIAL IMAGING OF MCALLEN LLC

Provider Business Mailing Address
First Line	:	5000 N 10TH ST
Second Line	:
City	:	MCALLEN
State	:	TX
Zip	:	78504-2832
Country	:	US
Telephone Number	:	956-686-2052
Fax Number	:

Provider Business Practice Location Address
First Line	:	5000 N 10TH ST
Second Line	:
City	:	MCALLEN
State	:	TX
Zip	:	78504-2832
Country	:	US
Telephone Number	:	956-686-2052
Fax Number	:	956-682-1749

Authorized Official
Title or Position	:	IMAGING COORDINATOR
Name	:	DR. KENNETH W BAKER
Credential	:
Telephone Number	:	956-686-2052

Provider Enumeration Date	:	04/14/2011
Last Update Date	:	04/14/2011

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