Healthcare Provider Details

I. General information

NPI: 1952138117
Provider Name (Legal Business Name): MARYLAND IMAGING NETWORK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 ODONNELL PL STE 100
WALDORF MD
20603-7290
US

IV. Provider business mailing address

10461 MILL RUN CIR STE 1020
OWINGS MILLS MD
21117-5544
US

V. Phone/Fax

Practice location:
  • Phone: 410-298-0454
  • Fax: 301-694-2606
Mailing address:
  • Phone: 443-436-1221
  • Fax: 443-436-1256

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 Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN VERNON CRUES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-445-2843