Provider Demographics
NPI:1689639205
Name:TIDC-GRAPEVINE, INC
Entity type:Organization
Organization Name:TIDC-GRAPEVINE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EMIL
Authorized Official - Middle Name:GEORGIO
Authorized Official - Last Name:CERULLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-357-5229
Mailing Address - Street 1:5311 WILLIAM D TATE AVE
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7365
Mailing Address - Country:US
Mailing Address - Phone:817-267-9500
Mailing Address - Fax:817-545-9400
Practice Address - Street 1:5311 WILLIAM D TATE AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7365
Practice Address - Country:US
Practice Address - Phone:817-267-9500
Practice Address - Fax:817-545-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR224102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTUXV3Medicare ID - Type Unspecified