Provider Demographics
NPI:1548208556
Name:RIVERDALE VASCULAR CENTER LLC
Entity Type:Organization
Organization Name:RIVERDALE VASCULAR CENTER LLC
Other - Org Name:HEALTH CONNECTIONS LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MADHU
Authorized Official - Middle Name:MOHAN
Authorized Official - Last Name:KATIKINENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-427-1755
Mailing Address - Street 1:PO BOX 6324
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-6324
Mailing Address - Country:US
Mailing Address - Phone:240-427-1755
Mailing Address - Fax:240-427-1795
Practice Address - Street 1:6510 KENILWORTH AVE
Practice Address - Street 2:SUITE 1100
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1339
Practice Address - Country:US
Practice Address - Phone:240-427-1755
Practice Address - Fax:240-427-1795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00183382085R0202X
MDD0025377208600000X
MDD00246442086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG02118Medicare ID - Type Unspecified
MDC62030Medicare UPIN
MDC62418Medicare UPIN
MDB94310Medicare UPIN
MDB93808Medicare UPIN