Provider Demographics
NPI:1124241807
Name:NORTHERN VIRGINIA RADIOLOGY AND NUCLEAR MEDICINE,INC
Entity type:Organization
Organization Name:NORTHERN VIRGINIA RADIOLOGY AND NUCLEAR MEDICINE,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PANOS
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOUTROUVELIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-356-9674
Mailing Address - Street 1:8320 OLD COURTHOUSE RD
Mailing Address - Street 2:#150
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3831
Mailing Address - Country:US
Mailing Address - Phone:703-356-9674
Mailing Address - Fax:703-356-9589
Practice Address - Street 1:8320 OLD COURTHOUSE RD
Practice Address - Street 2:#150
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3831
Practice Address - Country:US
Practice Address - Phone:703-356-9674
Practice Address - Fax:703-356-9589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA039101OtherANTHEM
VA7204876Medicaid
VA7857OtherCAREFIRST
410056Medicare ID - Type Unspecified