Provider Demographics
NPI:1326009721
Name:MCCOURT, AMY R (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:MCCOURT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4777 US HIGHWAY 259
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7668
Mailing Address - Country:US
Mailing Address - Phone:903-663-7393
Mailing Address - Fax:903-663-7394
Practice Address - Street 1:6901 MEDICAL PKWY
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7910
Practice Address - Country:US
Practice Address - Phone:903-663-7393
Practice Address - Fax:903-663-7394
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL13872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J0550OtherBLUE CROSS BLUE SHIELD
TX151702101Medicaid
TX161422401Medicaid
TX151702101Medicaid
TX8J0550OtherBLUE CROSS BLUE SHIELD
H57812Medicare UPIN