Provider Demographics
NPI:1942424452
Name:GED MEDICAL MANAGEMENT INC
Entity Type:Organization
Organization Name:GED MEDICAL MANAGEMENT INC
Other - Org Name:DIAGNOSTIC PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:IRA
Authorized Official - Last Name:ETTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:817-877-3054
Mailing Address - Street 1:2001 COOPER STREET
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-877-3054
Mailing Address - Fax:817-546-0851
Practice Address - Street 1:2001 COOPER STREET
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-877-3054
Practice Address - Fax:817-546-0851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1200X
TXR29901261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0533DCOtherBLUE CROSS PROVIDER NUMBE
TXR29901OtherSTATE LISC.#
TX=========OtherTIN NUMBER
TXFTX188Medicare ID - Type UnspecifiedMEDICARE NUMBER