Provider Demographics
NPI:1073654141
Name:MOBILE DIAGNOSTIC SERVICES, INC.
Entity Type:Organization
Organization Name:MOBILE DIAGNOSTIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:III
Authorized Official - Credentials:RDMS
Authorized Official - Phone:302-239-7700
Mailing Address - Street 1:25 S OLD BALTIMORE PIKE
Mailing Address - Street 2:STE 104
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-1540
Mailing Address - Country:US
Mailing Address - Phone:302-292-2700
Mailing Address - Fax:302-292-2702
Practice Address - Street 1:25 S OLD BALTIMORE PIKE
Practice Address - Street 2:STE 104
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-1540
Practice Address - Country:US
Practice Address - Phone:302-292-2700
Practice Address - Fax:302-292-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2013-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE19900328192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405833000Medicaid
TX574438109OtherUNITED AMERICAN INSURANCE
PA000330426OtherHIGHMARK INC
TX0005018072OtherAETNA
PA021642OtherHIGHMARK MEDICARE
AZX000596201Medicaid
TX0005018072OtherAETNA
DE=========Medicaid
PA000330426OtherHIGHMARK INC
TX574438109OtherUNITED AMERICAN INSURANCE
PA000330426OtherHIGHMARK INC