Provider Demographics
NPI:1962410308
Name:BALCONES IMAGING CONSULTANTS PA
Entity type:Organization
Organization Name:BALCONES IMAGING CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MIREUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-963-5360
Mailing Address - Street 1:PO BOX 301869
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-0032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 TAMRANAE CT.
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-0032
Practice Address - Country:US
Practice Address - Phone:512-963-5360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191318801Medicaid
TX191318801Medicaid
TXDG2704Medicare PIN