Provider Demographics
NPI:1891755468
Name:WACO RADIOLOGY PA
Entity Type:Organization
Organization Name:WACO RADIOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANGER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-321-8125
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-0103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 LONDONDERRY DR
Practice Address - Street 2:STE 104
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7924
Practice Address - Country:US
Practice Address - Phone:469-757-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C377OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX081864301Medicaid
TX00C377Medicare PIN