Provider Demographics
NPI:1609831379
Name:MEDICAL IMAGING DIAGNOSTIC ASSOCIATES
Entity Type:Organization
Organization Name:MEDICAL IMAGING DIAGNOSTIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WALTON
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-906-0969
Mailing Address - Street 1:PO BOX 1888
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75403-1888
Mailing Address - Country:US
Mailing Address - Phone:800-945-2455
Mailing Address - Fax:903-453-2541
Practice Address - Street 1:700 N AIRPORT RD
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332
Practice Address - Country:US
Practice Address - Phone:361-661-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127265002Medicaid
TX00A96JMedicare PIN