Provider Demographics
NPI:1053302042
Name:MOBILE MEDICAL RADIOGRAPHY AND EKG INC
Entity type:Organization
Organization Name:MOBILE MEDICAL RADIOGRAPHY AND EKG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:MINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE MEDEIROS
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:508-923-6171
Mailing Address - Street 1:109 RHODE ISLAND RD
Mailing Address - Street 2:CLEAR POND OFFICES
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-1370
Mailing Address - Country:US
Mailing Address - Phone:508-923-6171
Mailing Address - Fax:508-923-6248
Practice Address - Street 1:109 RHODE ISLAND RD
Practice Address - Street 2:CLEAR POND OFFICES
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-1370
Practice Address - Country:US
Practice Address - Phone:508-923-6171
Practice Address - Fax:508-923-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA08305335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME209805OtherMEDICARE PROVIDER NUMBER
MA1536591Medicaid
ME209805OtherMEDICARE PROVIDER NUMBER