Provider Demographics
NPI:1447341797
Name:MEMORIAL MRI & DIAGNOSTIC, LLC
Entity type:Organization
Organization Name:MEMORIAL MRI & DIAGNOSTIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JORRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FATHEREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-461-3399
Mailing Address - Street 1:PO BOX 802185
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77280-2185
Mailing Address - Country:US
Mailing Address - Phone:713-461-3399
Mailing Address - Fax:713-461-1969
Practice Address - Street 1:8800 KATY FWY STE 105
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-1645
Practice Address - Country:US
Practice Address - Phone:713-461-3399
Practice Address - Fax:713-461-1969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL05997207U00000X, 207UN0901X, 207UN0902X, 207UN0903X, 2085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
No207UN0903XAllopathic & Osteopathic PhysiciansNuclear MedicineIn Vivo & In Vitro Nuclear MedicineGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0203DCOtherBLUE CROSS, BLUE SHIELD
TX153985002Medicaid
TX0203DCOtherBLUE CROSS, BLUE SHIELD