Basic Information
| Provider Information | |||||||||
| NPI: | 1720079254 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL CENTER RADIOLOGISTS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41115 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235411115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574660089 | ||||||||
| FaxNumber: | 7574668017 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 GRESHAM DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573383231 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | SPECHT | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES OF MED CTR RADIOLOGISTS INC | ||||||||
| AuthorizedOfficialTelephone: | 7574660089 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 165565 | 01 | VA | OPTIMA | OTHER | CA5826 | 01 | VA | RR MEDICARE | OTHER | 02126 | 01 | NC | BCBS | OTHER | 100042 | 01 | VA | SENTARA | OTHER | 139178 | 01 | VA | BCBS | OTHER | 1720079254 | 05 | VA | MEDICAID | 165565 | 01 | VA | SENTARA | OTHER | 100042 | 01 | VA | OPTIMA | OTHER | 8902126 | 05 | NC | MEDICAID |