Provider Demographics
NPI:1154385102
Name:TIDC-IRVING, INC
Entity type:Organization
Organization Name:TIDC-IRVING, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EMIL
Authorized Official - Middle Name:GEORGIO
Authorized Official - Last Name:CERULLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-357-5229
Mailing Address - Street 1:3636 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-3637
Mailing Address - Country:US
Mailing Address - Phone:972-255-9444
Mailing Address - Fax:972-570-4664
Practice Address - Street 1:3636 N MACARTHUR BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-3637
Practice Address - Country:US
Practice Address - Phone:972-255-9444
Practice Address - Fax:972-570-4664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR224102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTA069Medicare ID - Type UnspecifiedIDTF