1972829372 NPI number — ELEVATED DIAGNOSTIC IMAGING AND PAIN MANAGEMENT CENTER LLC

Table of content: (NPI 1972829372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972829372 NPI number — ELEVATED DIAGNOSTIC IMAGING AND PAIN MANAGEMENT CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELEVATED DIAGNOSTIC IMAGING AND PAIN MANAGEMENT CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EDI LLC.
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972829372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5045 BROOKSTONE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46268-5420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-504-1665
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1642 OLIVE BRANCH PARK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46143-6447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-504-1665
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
LAMONT
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
317-504-1665

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  261QM1200X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X , with the licence number: 261QM1300X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP1100X , with the licence number: 261QP1100X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP3300X , with the licence number: 261QP3300X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0200X , with the licence number: 261QR0200X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)