Provider Demographics
NPI:1639441017
Name:ELITE NUCLEAR CARDIO DIAGNOSTICS
Entity Type:Organization
Organization Name:ELITE NUCLEAR CARDIO DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ENYOGAI
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATION
Authorized Official - Phone:301-483-7999
Mailing Address - Street 1:3207 BARCOFT DRIVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774
Mailing Address - Country:US
Mailing Address - Phone:240-899-5315
Mailing Address - Fax:301-483-7099
Practice Address - Street 1:3207 BARCROFT DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-2581
Practice Address - Country:US
Practice Address - Phone:240-899-5315
Practice Address - Fax:301-483-7099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0026012261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD502474Medicaid