1801895081 NPI number — MARION GENERAL RADIOLOGY, INC.

Table of content: (NPI 1801895081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801895081 NPI number — MARION GENERAL RADIOLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARION GENERAL RADIOLOGY, INC.
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:
1801895081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 N BALDWIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46952-2542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-288-8325
Provider Business Mailing Address Fax Number:
419-866-5453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 N WABASH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46952-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-288-8325
Provider Business Practice Location Address Fax Number:
419-866-5453
Provider Enumeration Date:
07/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DEAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
800-288-8325

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100282670B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000101047 . This is a "BC BS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100282670C , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100282670A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100282670D , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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