Provider Demographics
NPI:1821417494
Name:NORTHEAST MEDICAL CENTER RADIOLOGY, PA
Entity Type:Organization
Organization Name:NORTHEAST MEDICAL CENTER RADIOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BENTLEY
Authorized Official - Last Name:KAMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-260-1071
Mailing Address - Street 1:680 E BASSE RD
Mailing Address - Street 2:#203
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-7431
Mailing Address - Country:US
Mailing Address - Phone:210-260-1071
Mailing Address - Fax:210-822-4319
Practice Address - Street 1:680 E BASSE RD
Practice Address - Street 2:#203
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-7431
Practice Address - Country:US
Practice Address - Phone:210-260-1071
Practice Address - Fax:210-822-4319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF48942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAK8899708OtherDEA REGISTRATION NUMBER