Provider Demographics
NPI:1538134788
Name:SOUTHWEST MEDICAL IMAGING PA
Entity Type:Organization
Organization Name:SOUTHWEST MEDICAL IMAGING PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:432-570-1421
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79704-5500
Mailing Address - Country:US
Mailing Address - Phone:432-570-1421
Mailing Address - Fax:432-570-1427
Practice Address - Street 1:2200 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6407
Practice Address - Country:US
Practice Address - Phone:432-570-1421
Practice Address - Fax:432-570-1427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA001OtherSWMI TRICARE GRP PROV #
TX00T02KOtherSWMI BCBS PROV GRP #
TX112619501Medicaid
TX00T02KOtherSWMI BCBS PROV GRP #
TXCR0965Medicare PIN