Provider Demographics
NPI:1700830114
Name:MIB PARTNERSHIP LLP
Entity Type:Organization
Organization Name:MIB PARTNERSHIP LLP
Other - Org Name:MEDICAL IMAGING OF BALTIMORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LISSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-650-9000
Mailing Address - Street 1:PO BOX 630277
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-0277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6715 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6822
Practice Address - Country:US
Practice Address - Phone:410-296-5610
Practice Address - Fax:410-296-2982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM270174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD258LMedicare ID - Type Unspecified