=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417915711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TYSONS CORNER DIAGNOSTIC IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 01/25/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8320 OLD COURTHOUSE RD STE 130
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-3848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-356-4900
-----------------------------------------------------
Fax | 703-356-4602
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3480 PRESTON RIDGE RD STE 600
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30005-5462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-992-7255
-----------------------------------------------------
Fax | 678-992-7455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. BRUCE ELDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-992-7255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------