Basic Information
| Provider Information | |||||||||
| NPI: | 1699711093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGIC ASSOCIATES OF FREDERICKSBURG LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10401 SPOTSYLVANIA AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224088606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403611000 | ||||||||
| FaxNumber: | 5403617010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 SAM PERRY BLVD | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224014453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407411571 | ||||||||
| FaxNumber: | 5403617010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | GLASSER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5403611000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 56297 | 01 | VA | SOUTHERN HEALTH | OTHER | 015792 | 01 | VA | ANTHEM | OTHER | 3171 | 01 | VA | CAREFIRST | OTHER | 217998 | 01 | VA | MAMSI | OTHER |