Provider Demographics
NPI:1992839518
Name:MED TEL INTERNATIONAL CORPORATION
Entity Type:Organization
Organization Name:MED TEL INTERNATIONAL CORPORATION
Other - Org Name:WIDE OPEN IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-873-9850
Mailing Address - Street 1:1430 SPRING HILL RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3000
Mailing Address - Country:US
Mailing Address - Phone:703-287-4189
Mailing Address - Fax:703-448-1807
Practice Address - Street 1:405 PHOENIX DR
Practice Address - Street 2:UNIT A
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-4534
Practice Address - Country:US
Practice Address - Phone:717-263-4999
Practice Address - Fax:717-263-5522
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MED TEL INTERNATIOANL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-15
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA20-488572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018487550005Medicaid
PA0018487550005Medicaid