Basic Information
| Provider Information | |||||||||
| NPI: | 1215319751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOMGARDEN | ||||||||
| FirstName: | ERICH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 UNIVERSITY BLVD | ||||||||
| Address2: | ROOM 0641 - DEPARTMENT OF RADIOLOGY AND IMAGING SCIENCE | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179482449 | ||||||||
| FaxNumber: | 3179482803 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 UNIVERSITY BLVD | ||||||||
| Address2: | ROOM 0641 - DEPARTMENT OF RADIOLOGY AND IMAGING SCIENCE | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179482449 | ||||||||
| FaxNumber: | 3179482803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2015 | ||||||||
| LastUpdateDate: | 06/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2015017146 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 11018610A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.