Provider Demographics
NPI:1669470241
Name:THE MEDICAL SHOP, INC
Entity Type:Organization
Organization Name:THE MEDICAL SHOP, INC
Other - Org Name:TEXAS IMAGING & DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EMIL
Authorized Official - Middle Name:GEORGIO
Authorized Official - Last Name:CERULLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-357-5229
Mailing Address - Street 1:3840 W NORTHWEST HWY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-5162
Mailing Address - Country:US
Mailing Address - Phone:214-357-5229
Mailing Address - Fax:214-357-5488
Practice Address - Street 1:3840 W NORTHWEST HWY
Practice Address - Street 2:SUITE 400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-5162
Practice Address - Country:US
Practice Address - Phone:214-357-5229
Practice Address - Fax:214-357-5488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR21910247100000X, 2471C3401X, 2471C3402X, 2471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
Not Answered2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Multi-Specialty
Not Answered2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
Not Answered2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTX099Medicare ID - Type UnspecifiedIDFT