1013217769 NPI number — SYMPHONY DIAGNOSTIC SERVICES NO 1 LLC

Table of content: (NPI 1013217769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013217769 NPI number — SYMPHONY DIAGNOSTIC SERVICES NO 1 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYMPHONY DIAGNOSTIC SERVICES NO 1 LLC
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:
Provider Other Organization Name Type Code:
6
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:
1013217769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 RIDGEBROOK RD
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
SPARKS GLENCOE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21152-9390
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-786-8015
Provider Business Mailing Address Fax Number:
443-662-4230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 RIDGEBROOK RD
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
SPARKS GLENCOE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21152-9390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-786-8015
Provider Business Practice Location Address Fax Number:
443-662-4230
Provider Enumeration Date:
10/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CUOMO
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
AUTHORIZED OFFICIAL/CFO
Authorized Official Telephone Number:
800-786-8015

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9000189649 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: Z242004 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013217769 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2374656 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 095566 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 630001673 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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