Provider Demographics
NPI:1528121340
Name:GALAXY MRI AND DIAGNOSTIC CENTER
Entity type:Organization
Organization Name:GALAXY MRI AND DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TEIG
Authorized Official - Last Name:PORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-331-4481
Mailing Address - Street 1:1110 N GALLOWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-2436
Mailing Address - Country:US
Mailing Address - Phone:972-331-4481
Mailing Address - Fax:972-331-4486
Practice Address - Street 1:1110 N GALLOWAY AVE
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-2436
Practice Address - Country:US
Practice Address - Phone:972-331-4481
Practice Address - Fax:972-331-4486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246XS1301X, 261QM1200X, 2471S1302X, 2471V0105X, 293D00000X, 261QR0200X
TXR296082471C3401X, 2471C3402X
TX2471M1202X
TX45D1103817291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Multi-Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Multi-Specialty
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Multi-Specialty
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
No2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
No293D00000XLaboratoriesPhysiological Laboratory
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179171701Medicaid
TX45D1103817OtherCLIA
TX45D1103817OtherCLIA