Provider Demographics
NPI:1255399507
Name:UVA OUTPATIENT IMAGING CENTREVILLE LLC
Entity type:Organization
Organization Name:UVA OUTPATIENT IMAGING CENTREVILLE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:CODER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-835-2069
Mailing Address - Street 1:PO BOX 931912
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-1912
Mailing Address - Country:US
Mailing Address - Phone:866-659-1211
Mailing Address - Fax:336-774-1751
Practice Address - Street 1:6208 MULTIPLEX DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-5324
Practice Address - Country:US
Practice Address - Phone:703-825-2244
Practice Address - Fax:703-830-3610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010062381Medicaid
7217512OtherAETNA
P00450165OtherMEDICARE RAILROAD
VA185293OtherBC
J428OtherCAREFIRST
VA185293OtherBC