Provider Demographics
NPI:1245236132
Name:LUBBOCK RADIOLOGY LP
Entity Type:Organization
Organization Name:LUBBOCK RADIOLOGY LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
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 2160
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-2160
Mailing Address - Country:US
Mailing Address - Phone:806-792-2767
Mailing Address - Fax:806-791-6709
Practice Address - Street 1:3707 21ST ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1219
Practice Address - Country:US
Practice Address - Phone:806-792-2767
Practice Address - Fax:806-791-6709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QR0200X, 293D00000X
293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1895212OtherFIRST HEALTH
470001572OtherRR MEDICARE
TXJ730OtherBLUE CROSS
NMW6027Medicaid
TX104497100OtherFIRSTCARE
TX153651801Medicaid
TX153651801Medicaid