Provider Demographics
NPI:1780620674
Name:MOBILE X-RAY OF AMARILLO
Entity type:Organization
Organization Name:MOBILE X-RAY OF AMARILLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-676-8960
Mailing Address - Street 1:4303 S FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79110-1708
Mailing Address - Country:US
Mailing Address - Phone:806-676-8960
Mailing Address - Fax:
Practice Address - Street 1:4303 SOUTH FANNIN
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79110-0000
Practice Address - Country:US
Practice Address - Phone:806-371-6717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12900335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX086093401Medicaid
630000608OtherRAILROAD MEDICARE