Provider Demographics
NPI:1508376716
Name:NEURO IR OF EAST TEXAS
Entity Type:Organization
Organization Name:NEURO IR OF EAST TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-705-0072
Mailing Address - Street 1:700 OLYMPIC PLAZA CIR STE 910
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1915
Mailing Address - Country:US
Mailing Address - Phone:903-705-0072
Mailing Address - Fax:903-705-0068
Practice Address - Street 1:700 OLYMPIC PLAZA CIR STE 910
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1915
Practice Address - Country:US
Practice Address - Phone:903-705-0072
Practice Address - Fax:903-705-0068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2023-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty