Provider Demographics
NPI:1568403046
Name:SOUTHLAKE TROPHY CLUB RADIOLOGY
Entity Type:Organization
Organization Name:SOUTHLAKE TROPHY CLUB RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-908-7810
Mailing Address - Street 1:2155 N PEARSON LN
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-9016
Mailing Address - Country:US
Mailing Address - Phone:817-908-7810
Mailing Address - Fax:206-337-0544
Practice Address - Street 1:2800 SOUTH HIGHWAY 114
Practice Address - Street 2:
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76726
Practice Address - Country:US
Practice Address - Phone:817-908-7810
Practice Address - Fax:206-337-0544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL10912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG67126Medicare UPIN