Provider Demographics
NPI:1427101955
Name:MOODY DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:MOODY DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS, RDCS, RVS
Authorized Official - Phone:903-723-5345
Mailing Address - Street 1:PO BOX 1838
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75802-1838
Mailing Address - Country:US
Mailing Address - Phone:903-723-5345
Mailing Address - Fax:903-723-5343
Practice Address - Street 1:104 TRINITY PLACE
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801
Practice Address - Country:US
Practice Address - Phone:903-723-5345
Practice Address - Fax:903-723-5343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146693001Medicaid
TX0013DCOtherBCBS
TXFTCVU3Medicare ID - Type Unspecified