Basic Information
| Provider Information | |||||||||
| NPI: | 1477591873 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC IMAGING ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 79915 | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212790915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432742900 | ||||||||
| FaxNumber: | 4432742391 | ||||||||
| Practice Location | |||||||||
| Address1: | 8118 GOOD LUCK RD | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207063595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012490022 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | STALLINGS | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD/PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3012490022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | H800DI | 01 | MD | BCBS GROUP PROVIDER # | OTHER | 7926 | 01 | DC | BCBS GROUP PROVIDER # | OTHER | 403703102 | 05 | MD | MEDICAID |