Healthcare Provider Details

I. General information

NPI: 1528627734
Provider Name (Legal Business Name): RADIOLOGY INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12731 MARBLESTONE DR STE 105
WOODBRIDGE VA
22192-8334
US

IV. Provider business mailing address

12731 MARBLESTONE DR STE 105
WOODBRIDGE VA
22192-8334
US

V. Phone/Fax

Practice location:
  • Phone: 703-269-0704
  • Fax:
Mailing address:
  • Phone: 703-269-0704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. SHAHIN J KORANGY
Title or Position: OWNER
Credential: MD
Phone: 703-269-0704