Provider Demographics
NPI:1104012699
Name:MEMORIAL HERMANN HEALTH SYSTEM
Entity Type:Organization
Organization Name:MEMORIAL HERMANN HEALTH SYSTEM
Other - Org Name:MEMORIAL HERMANN OUTPATIENT IMAGING-SOUTHWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LARAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-242-2707
Mailing Address - Street 1:PO BOX 301208
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75303-1208
Mailing Address - Country:US
Mailing Address - Phone:713-338-4127
Mailing Address - Fax:713-338-4158
Practice Address - Street 1:7789 SOUTHWEST FWY
Practice Address - Street 2:SUITE 150
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1829
Practice Address - Country:US
Practice Address - Phone:713-338-4127
Practice Address - Fax:713-338-4158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185684101Medicaid