Healthcare Provider Details

I. General information

NPI: 1467996959
Provider Name (Legal Business Name): UNIVERSITY OF MARYLAND DIAGNOSTIC RADIOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 N LA PLATA CT STE 104
LA PLATA MD
20646-5207
US

IV. Provider business mailing address

PO BOX 829688
PHILADELPHIA PA
19182-9688
US

V. Phone/Fax

Practice location:
  • Phone: 301-539-0345
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES S WHITE
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 410-328-3477