Provider Demographics
NPI:1528022480
Name:MAIDEN CHOICE NUCLEAR IMAGING CENTER
Entity Type:Organization
Organization Name:MAIDEN CHOICE NUCLEAR IMAGING CENTER
Other - Org Name:ST AGNES NUCLEAR IMAGING
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT OF BOARD
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:410-747-3300
Mailing Address - Street 1:724 MAIDEN CHOICE LN
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5911
Mailing Address - Country:US
Mailing Address - Phone:410-747-3300
Mailing Address - Fax:410-455-0009
Practice Address - Street 1:724 MAIDEN CHOICE LN
Practice Address - Street 2:SUITE 202
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-5911
Practice Address - Country:US
Practice Address - Phone:410-747-3300
Practice Address - Fax:410-455-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD05121012085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD265080100Medicaid
115LMedicare ID - Type Unspecified