Provider Demographics
NPI:1407929474
Name:RIO GRANDE DIAGNOSTIC IMAGING, PA
Entity Type:Organization
Organization Name:RIO GRANDE DIAGNOSTIC IMAGING, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:SAM
Authorized Official - Last Name:KUPETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-731-7771
Mailing Address - Street 1:PO BOX 101957
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76185-1957
Mailing Address - Country:US
Mailing Address - Phone:817-731-7771
Mailing Address - Fax:817-731-7774
Practice Address - Street 1:1801 N OREGON ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3524
Practice Address - Country:US
Practice Address - Phone:915-595-9202
Practice Address - Fax:915-595-9781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0003EEOtherBCBS
TX00077304Medicaid
TXCG5428OtherMEDICARE RR
TX095053701Medicaid
TX201074651Medicaid
TX095053701Medicaid