Basic Information
| Provider Information | |||||||||
| NPI: | 1306898168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE MEDICAL IMAGING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5602 | ||||||||
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| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468955602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604719466 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3250 INTERTECH PARKWAY | ||||||||
| Address2: | SUITE D | ||||||||
| City: | ANGOLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467037223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606653200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 09/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | KINZER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2604719466 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.