Provider Demographics
NPI:1154387231
Name:GRAPEVINE RADIOLOGY ASSOCIATES
Entity type:Organization
Organization Name:GRAPEVINE RADIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:FOREST
Authorized Official - Last Name:WOOMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-488-7546
Mailing Address - Street 1:PO BOX 740968
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374-0968
Mailing Address - Country:US
Mailing Address - Phone:800-563-2964
Mailing Address - Fax:903-453-2541
Practice Address - Street 1:1650 W COLLEGE STREET
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051
Practice Address - Country:US
Practice Address - Phone:817-488-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093777301Medicaid
TX00L26BMedicare PIN
TX093777301Medicaid
TXDB8465Medicare PIN