Provider Demographics
NPI:1407964539
Name:EAST TEXAS HEART & VASCULAR IMAGING LTD
Entity Type:Organization
Organization Name:EAST TEXAS HEART & VASCULAR IMAGING LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAVINDER
Authorized Official - Middle Name:R
Authorized Official - Last Name:BACHIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-632-8787
Mailing Address - Street 1:310 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3133
Mailing Address - Country:US
Mailing Address - Phone:936-632-8787
Mailing Address - Fax:936-632-8832
Practice Address - Street 1:310 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3133
Practice Address - Country:US
Practice Address - Phone:936-632-8787
Practice Address - Fax:936-632-8832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX048374502Medicaid
TXHH1819OtherBLUECROSS BLUESHIELD OF TEXAS
TX048374502Medicaid