Basic Information
| Provider Information | |||||||||
| NPI: | 1649543141 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNERVISION ADVANCED MEDICAL IMAGING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
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| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654492732 | ||||||||
| FaxNumber: | 7654465317 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 S CREASY LANE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479057433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654477447 | ||||||||
| FaxNumber: | 7654465317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2012 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING | ||||||||
| AuthorizedOfficialTelephone: | 7654465417 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085B0100X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
No ID Information.