Basic Information
| Provider Information | |||||||||
| NPI: | 1851829550 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INOVA HEALTH CARE SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RADIOLOGY IMAGING ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37174 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5714235699 | ||||||||
| FaxNumber: | 5714235698 | ||||||||
| Practice Location | |||||||||
| Address1: | 11335 PEMBROOKE SQ STE 101 | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019324522 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2017 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POPE | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7032892048 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INOVA HEALTH CARE SERVICES | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1851829550 | 05 | VA | MEDICAID |