Provider Demographics
NPI:1790921088
Name:BIOTECH X-RAY, INC.
Entity Type:Organization
Organization Name:BIOTECH X-RAY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:BISHOP
Authorized Official - Last Name:SCHWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-449-1669
Mailing Address - Street 1:1065 EXECUTIVE PARKWAY DR STE 220
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6367
Mailing Address - Country:US
Mailing Address - Phone:314-548-2900
Mailing Address - Fax:314-548-2920
Practice Address - Street 1:1065 EXECUTIVE PARKWAY DR STE 220
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6367
Practice Address - Country:US
Practice Address - Phone:314-548-2900
Practice Address - Fax:314-548-2920
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BIOTECH X-RAY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-17
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000047082293D00000X
IL216464293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216464OtherMEDICARE PTAN
MO000047082OtherMEDICARE PTAN