Provider Demographics
NPI:1902823727
Name:VIRGINIA VASCULAR IMAGING LLC
Entity Type:Organization
Organization Name:VIRGINIA VASCULAR IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-654-9118
Mailing Address - Street 1:2809 EMERYWOOD PKWY
Mailing Address - Street 2:STE 210
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294
Mailing Address - Country:US
Mailing Address - Phone:804-756-5130
Mailing Address - Fax:804-672-6899
Practice Address - Street 1:1201 SAM PERRY BLVD # B
Practice Address - Street 2:STE 265
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4490
Practice Address - Country:US
Practice Address - Phone:540-654-9118
Practice Address - Fax:540-654-9116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1902823727Medicaid
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