Provider Demographics
NPI:1417915711
Name:TYSON'S CORNER DIAGNOSTIC IMAGING INC
Entity Type:Organization
Organization Name:TYSON'S CORNER DIAGNOSTIC IMAGING INC
Other - Org Name:TYSONS CORNER DIAGNOSTIC IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-992-7255
Mailing Address - Street 1:3480 PRESTON RIDGE RD STE 600
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5462
Mailing Address - Country:US
Mailing Address - Phone:678-992-7255
Mailing Address - Fax:678-992-7455
Practice Address - Street 1:8320 OLD COURTHOUSE RD
Practice Address - Street 2:SUITE 130-B
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3831
Practice Address - Country:US
Practice Address - Phone:703-356-4900
Practice Address - Fax:703-356-4602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S372OtherCAREFIRST
VA004991397Medicaid
470001480OtherMEDICARE RR
VA004991397Medicaid
7983306OtherAETNA
S372OtherCAREFIRST
150869000OtherDOL