Provider Demographics
NPI:1851457246
Name:MIDATLANTIC DIAGNOSTIC IMAGING CENTERS LLC
Entity Type:Organization
Organization Name:MIDATLANTIC DIAGNOSTIC IMAGING CENTERS LLC
Other - Org Name:ELICOTT OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-480-0082
Mailing Address - Street 1:3570 SAINT JOHNS LN
Mailing Address - Street 2:SUITE 104 B
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-4020
Mailing Address - Country:US
Mailing Address - Phone:410-480-0082
Mailing Address - Fax:
Practice Address - Street 1:3570 SAINT JOHNS LN
Practice Address - Street 2:SUITE 104 B
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-4020
Practice Address - Country:US
Practice Address - Phone:410-480-0082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCK676OtherGHI
MD970BELOtherBLUE SHIELD
MD970BELOtherBLUE SHIELD
MDFMX019Medicare PIN