Provider Demographics
NPI:1770696007
Name:THE HEART DOCTOR IMAGING CENTER
Entity type:Organization
Organization Name:THE HEART DOCTOR IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:G
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:936-564-2828
Mailing Address - Street 1:5124 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1368
Mailing Address - Country:US
Mailing Address - Phone:936-564-2828
Mailing Address - Fax:936-569-1956
Practice Address - Street 1:5124 NORTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1368
Practice Address - Country:US
Practice Address - Phone:936-564-2828
Practice Address - Fax:936-569-1956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH1822OtherBCBS FACILITY ID