Provider Demographics
NPI:1942209515
Name:NORTHWEST DIAGNOSTIC CLINIC, PA
Entity Type:Organization
Organization Name:NORTHWEST DIAGNOSTIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-232-5500
Mailing Address - Street 1:2255 E MOSSY OAKS RD STE 500
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-1813
Mailing Address - Country:US
Mailing Address - Phone:281-440-5300
Mailing Address - Fax:832-232-5591
Practice Address - Street 1:8845 SIX PINES DR FL 2
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-2675
Practice Address - Country:US
Practice Address - Phone:832-232-5500
Practice Address - Fax:832-232-5510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162607901Medicaid
TX00T359OtherBCBS OF TEXAS
TX00004TMedicare PIN
TXCB3944Medicare PIN