Provider Demographics
NPI:1316057664
Name:COLLEGE STATION IMAGING CENTER
Entity type:Organization
Organization Name:COLLEGE STATION IMAGING CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MARAIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-268-7500
Mailing Address - Street 1:1105 UNIVERSITY DR E
Mailing Address - Street 2:STE 102
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840
Mailing Address - Country:US
Mailing Address - Phone:979-268-7500
Mailing Address - Fax:979-268-7501
Practice Address - Street 1:1105 UNIVERSITY DR E
Practice Address - Street 2:STE 102
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840
Practice Address - Country:US
Practice Address - Phone:979-268-7500
Practice Address - Fax:979-268-7501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR273842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTVXU8Medicare ID - Type Unspecified