Provider Demographics
NPI:1366491557
Name:MAIDEN CHOICE CARDIAC DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:MAIDEN CHOICE CARDIAC DIAGNOSTIC CENTER
Other - Org Name:ST. AGNES CARDIAC DIAGNOSTIC CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:HOMAYOON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGHBELI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-455-0200
Mailing Address - Street 1:724 MAIDEN CHOICE LN
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5911
Mailing Address - Country:US
Mailing Address - Phone:410-455-0200
Mailing Address - Fax:410-455-0009
Practice Address - Street 1:724 MAIDEN CHOICE LN
Practice Address - Street 2:SUITE 203
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-5911
Practice Address - Country:US
Practice Address - Phone:410-455-0200
Practice Address - Fax:410-455-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD174680400Medicaid
MD174680400Medicaid