1659435055 NPI number — WOODBURN NUCLEAR MEDICINE, LTD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659435055 NPI number — WOODBURN NUCLEAR MEDICINE, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODBURN NUCLEAR MEDICINE, LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
METRO REGION PET
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659435055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3289 WOODBURN RD
Provider Second Line Business Mailing Address:
060
Provider Business Mailing Address City Name:
ANNANDALE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22003-6800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-698-0666
Provider Business Mailing Address Fax Number:
703-573-6120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3289 WOODBURN RD
Provider Second Line Business Practice Location Address:
060
Provider Business Practice Location Address City Name:
ANNANDALE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22003-6800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-698-0666
Provider Business Practice Location Address Fax Number:
703-573-6120
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NORBY
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
H
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
703-698-0666

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  0101041611 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036364400 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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