Healthcare Provider Details

I. General information

NPI: 1609270479
Provider Name (Legal Business Name): LIGHTSPEED RADIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9135 PISCATAWAY RD
CLINTON MD
20735-2549
US

IV. Provider business mailing address

PO BOX 54
MOUNT AIRY MD
21771-0054
US

V. Phone/Fax

Practice location:
  • Phone: 419-796-0306
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: NOURREDDINE GUAO GUAOUGUAOU
Title or Position: PRESIDENT
Credential: MD
Phone: 703-851-4310