Basic Information
| Provider Information | |||||||||
| NPI: | 1699072611 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMAGING ASSOCIATES OF INDIANA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 208807 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753208807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885016087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 S MAIN ST | ||||||||
| Address2: | ATTN: RADIOLOGY DEPARTMENT | ||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463078481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197676320 | ||||||||
| FaxNumber: | 2197386714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2011 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | CASSIN | ||||||||
| AuthorizedOfficialFirstName: | NAOMI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | AVP, PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 3127248477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | NONE | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | NONE | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 201016500 A-F | 05 | IN | MEDICAID |