MEDICARE: GED MEDICAL MANAGEMENT INC

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	261QR0200X	Radiology Clinic/Center	R29901	TX
2	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0533DC	OTHER	TX	BLUE CROSS PROVIDER NUMBE
2	R29901	OTHER	TX	STATE LISC.#

General Provider Information

NPI Number	:	1942424452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GED MEDICAL MANAGEMENT INC

Provider Business Mailing Address
First Line	:	2001 COOPER STREET
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104
Country	:	US
Telephone Number	:	817-877-3054
Fax Number	:	817-546-0851

Provider Business Practice Location Address
First Line	:	2001 COOPER STREET
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104
Country	:	US
Telephone Number	:	817-877-3054
Fax Number	:	817-546-0851

Authorized Official
Title or Position	:	CFO/PRESIDENT
Name	:	ALAN IRA ETTINGER
Credential	:	DPM
Telephone Number	:	817-877-3054

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	03/05/2012

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Directions to “GED MEDICAL MANAGEMENT INC ” Practice Location

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