1457380453 NPI number — IMAGI, LLC

Table of content: (NPI 1457380453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457380453 NPI number — IMAGI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMAGI, 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:
NORTHEAST INDIANA ENDOSCOPY CENTER
Provider Other Organization Name Type Code:
3
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:
1457380453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7900 W JEFFERSON BLVD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804-4128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-969-7100
Provider Business Mailing Address Fax Number:
260-969-7182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7900 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-4128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-969-7100
Provider Business Practice Location Address Fax Number:
260-969-7182
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STEELE
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
260-969-7100

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000210095 . This is a "ANTHEM IDENTIFICATION NUM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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