Provider Demographics
NPI:1639122039
Name:SHADY GROVE RADIOLOGICAL CONSULTANTS PA
Entity Type:Organization
Organization Name:SHADY GROVE RADIOLOGICAL CONSULTANTS PA
Other - Org Name:SHADY GROVE RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BUSCHING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-948-5700
Mailing Address - Street 1:20410 OBSERVATION DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-4000
Mailing Address - Country:US
Mailing Address - Phone:301-948-5700
Mailing Address - Fax:301-212-4277
Practice Address - Street 1:20410 OBSERVATION DR
Practice Address - Street 2:SUITE 104
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4000
Practice Address - Country:US
Practice Address - Phone:301-948-5700
Practice Address - Fax:301-212-4277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD979151500Medicaid
MD979151500Medicaid
MDCD1033Medicare PIN