Provider Demographics
NPI:1982651543
Name:SHORT PUMP IMAGING LLC
Entity Type:Organization
Organization Name:SHORT PUMP IMAGING LLC
Other - Org Name:INDEPENDENCE PARK IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:9930 INDEPENDENCE PARK DR
Mailing Address - Street 2:STE 100
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1446
Mailing Address - Country:US
Mailing Address - Phone:804-217-9729
Mailing Address - Fax:804-217-9584
Practice Address - Street 1:9930 INDEPENDENCE PARK DR
Practice Address - Street 2:STE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-1446
Practice Address - Country:US
Practice Address - Phone:804-217-9729
Practice Address - Fax:804-217-9584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010309107Medicaid
VA196918OtherBCBS OF VA
VA010309107Medicaid