Provider Demographics
NPI:1306062195
Name:MOBILE MEDICAL IMAGING, LLC
Entity type:Organization
Organization Name:MOBILE MEDICAL IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DESMOND
Authorized Official - Middle Name:COURTNEY
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:301-680-1900
Mailing Address - Street 1:12501 PROSPERITY DR
Mailing Address - Street 2:SUITE 455
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1689
Mailing Address - Country:US
Mailing Address - Phone:301-680-1900
Mailing Address - Fax:301-680-0920
Practice Address - Street 1:12501 PROSPERITY DR
Practice Address - Street 2:SUITE 455
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1689
Practice Address - Country:US
Practice Address - Phone:301-680-1900
Practice Address - Fax:301-680-0920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2017-04-20
Deactivation Date:2008-08-12
Deactivation Code:
Reactivation Date:2011-02-25
Provider Licenses
StateLicense IDTaxonomies
MD293D00000X, 293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC04697300Medicaid
P01391384OtherRAILROAD MEDICARE PIN
MD777788400Medicaid
DC04697300Medicaid
MD777788400Medicaid