Provider Demographics
NPI:1811189079
Name:FANNIN ST IMAGING
Entity type:Organization
Organization Name:FANNIN ST IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANNT
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-664-1330
Mailing Address - Street 1:2525 W BELLFORT ST
Mailing Address - Street 2:120
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-5000
Mailing Address - Country:US
Mailing Address - Phone:713-664-1330
Mailing Address - Fax:713-664-0327
Practice Address - Street 1:2616 S LOOP W
Practice Address - Street 2:170
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2662
Practice Address - Country:US
Practice Address - Phone:713-665-6767
Practice Address - Fax:713-666-2300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid
TX00R94RMedicare PIN