Provider Demographics
NPI:1871594697
Name:MODIFIED BARIUM SWALLOW SERVICE, P.A.
Entity type:Organization
Organization Name:MODIFIED BARIUM SWALLOW SERVICE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:REED
Authorized Official - Last Name:NILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-325-6277
Mailing Address - Street 1:3724 FM 346 E
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-8340
Mailing Address - Country:US
Mailing Address - Phone:210-325-6277
Mailing Address - Fax:210-682-5195
Practice Address - Street 1:3724 FM 346 E
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-8340
Practice Address - Country:US
Practice Address - Phone:210-325-6277
Practice Address - Fax:210-682-5195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL08822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty