Healthcare Provider Details

I. General information

NPI: 1649028358
Provider Name (Legal Business Name): MEDSTAR MEDICAL GROUP RADIOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 05/08/2024
Certification Date: 04/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW
WASHINGTON DC
20010-3017
US

IV. Provider business mailing address

3007 TILDEN ST NW STE 5N
WASHINGTON DC
20008-3030
US

V. Phone/Fax

Practice location:
  • Phone: 703-558-1403
  • Fax:
Mailing address:
  • Phone: 703-558-1403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE SCHNEIDER
Title or Position: VP
Credential:
Phone: 702-558-1403