Provider Demographics
NPI:1215028501
Name:LUBBOCK DIAGNOSTIC RADIOLOGY, L.L.P.
Entity Type:Organization
Organization Name:LUBBOCK DIAGNOSTIC RADIOLOGY, L.L.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDANICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-792-2767
Mailing Address - Street 1:PO BOX 1620
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-1620
Mailing Address - Country:US
Mailing Address - Phone:806-792-2767
Mailing Address - Fax:806-791-6709
Practice Address - Street 1:4005 24TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1835
Practice Address - Country:US
Practice Address - Phone:806-792-2767
Practice Address - Fax:888-861-8858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CG7043OtherRAILROAD MEDICARE
62866OtherNEW MEXICO MEDICAID
TX0094EEOtherBLUE CROSS
TX095055202Medicaid
TX00632NMedicare ID - Type Unspecified