Basic Information
| Provider Information | |||||||||
| NPI: | 1922562586 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOVIRGINIA IMAGING | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 715868 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191715868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049151910 | ||||||||
| FaxNumber: | 7038105369 | ||||||||
| Practice Location | |||||||||
| Address1: | 8320 OLD COURTHOUSE RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036674226 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2019 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | PROFFITT | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING/ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8045332357 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHOVIRGINA, INC. | ||||||||
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| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
No ID Information.