Provider Demographics
NPI:1013914613
Name:METHODIST DIAGNOSTIC IMAGING
Entity Type:Organization
Organization Name:METHODIST DIAGNOSTIC IMAGING
Other - Org Name:COVENANT DIAGNOSTIC IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY OF ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 2190
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-2190
Mailing Address - Country:US
Mailing Address - Phone:806-792-2767
Mailing Address - Fax:806-791-6709
Practice Address - Street 1:3525 19TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1202
Practice Address - Country:US
Practice Address - Phone:806-792-2767
Practice Address - Fax:806-791-6709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-29
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN/A2085B0100X, 261QR0200X, 293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOOF91YOtherBLUE CROSS
TX121741603OtherCROSSOVERMEDICAID
TX121741601Medicaid
NMG7966Medicaid
TX103173100OtherFIRSTCARE
DN6474OtherRAILROAD MEDICARE
TX121741601Medicaid