1225219652 NPI number — MED IMAGING OF INDIANA, LLC

Table of content: (NPI 1225219652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225219652 NPI number — MED IMAGING OF INDIANA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED IMAGING OF INDIANA, 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:
Provider Other Organization Name Type Code:
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:
1225219652
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6948 ALCOA RD
Provider Second Line Business Mailing Address:
SUITE K
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72015-9726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-778-9729
Provider Business Mailing Address Fax Number:
501-776-2695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2045 RAMA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46219-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-871-2790
Provider Business Practice Location Address Fax Number:
317-871-2792
Provider Enumeration Date:
11/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
501-786-0522

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200908550A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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