=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417131467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVE RADIOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2007
-----------------------------------------------------
Last Update Date | 12/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 176 THOMAS JOHNSON DR SUITE 103
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21702-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-694-2630
-----------------------------------------------------
Fax | 301-694-2307
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 176 THOMAS JOHNSON DR SUITE 103
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21702-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-694-2630
-----------------------------------------------------
Fax | 301-694-2307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MR. WILLIAM BONDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-694-2630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | M369
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------