Provider Demographics
NPI:1114328903
Name:MAHONEYMOBILEMEDICAL AND VASCULAR ACCESS SERVICE
Entity Type:Organization
Organization Name:MAHONEYMOBILEMEDICAL AND VASCULAR ACCESS SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:MAHONEY
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-421-0800
Mailing Address - Street 1:716 FIRESTONE DR
Mailing Address - Street 2:MAHONEYMOBILEMEDICAL AND VASCULAR ACCESS SERVICE
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-4087
Mailing Address - Country:US
Mailing Address - Phone:301-421-0800
Mailing Address - Fax:
Practice Address - Street 1:716 FIRESTONE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20905-4087
Practice Address - Country:US
Practice Address - Phone:301-421-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD20371174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD001984400/355661100Medicaid