Provider Demographics
NPI: | 1467670612 |
---|---|
Name: | MD MOBILE DIAGNOSTICS |
Entity Type: | Organization |
Organization Name: | MD MOBILE DIAGNOSTICS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MEDICAL DIRECTOR |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | GREG |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SMITH |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 410-274-9315 |
Mailing Address - Street 1: | 414 TWIN OAKS RD |
Mailing Address - Street 2: | |
Mailing Address - City: | LINTHICUM |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 21090-1208 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 410-274-9315 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 414 TWIN OAKS RD |
Practice Address - Street 2: | |
Practice Address - City: | LINTHICUM |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21090-1208 |
Practice Address - Country: | US |
Practice Address - Phone: | 410-274-9315 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-04-23 |
Last Update Date: | 2010-03-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 0101239876 | 208100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Single Specialty |