Provider Demographics
NPI:1316006513
Name:RADIOLOGY ASSOICATES OF TARRANT COUNTY PA
Entity type:Organization
Organization Name:RADIOLOGY ASSOICATES OF TARRANT COUNTY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:QUERALT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-321-0312
Mailing Address - Street 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-0387
Mailing Address - Fax:469-522-6889
Practice Address - Street 1:3400 CAMP BOWIE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2729
Practice Address - Country:US
Practice Address - Phone:817-321-0312
Practice Address - Fax:817-317-7033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2085U0001X, 2085B0100X, 2085P0229X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121715001Medicaid
TX121715001Medicaid