MEDICARE: RIVERDALE VASCULAR CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	D0018338	MD
2	208600000X	Surgery Physician	D0025377	MD
3	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	D0024644	MD
4	2086S0129X	Vascular Surgery Physician	D0024644	MD

General Provider Information

NPI Number	:	1548208556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERDALE VASCULAR CENTER LLC

Provider Business Mailing Address
First Line	:	PO BOX 6324
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20603-6324
Country	:	US
Telephone Number	:	240-427-1755
Fax Number	:	240-427-1795

Provider Business Practice Location Address
First Line	:	6510 KENILWORTH AVE
Second Line	:	SUITE 1100
City	:	RIVERDALE
State	:	MD
Zip	:	20737-1339
Country	:	US
Telephone Number	:	240-427-1755
Fax Number	:	240-427-1795

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MADHU MOHAN KATIKINENI
Credential	:	M.D.
Telephone Number	:	240-427-1755

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	04/15/2009

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Directions to “RIVERDALE VASCULAR CENTER LLC ” Practice Location

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