Basic Information
| Provider Information | |||||||||
| NPI: | 1871564336 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMAGING DIAGNOSTIC CENTER LIMITED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6119 W JEFFERSON BLVD | ||||||||
| Address2: | IMAGING DIAGNOSTIC CENTER | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468043072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604321568 | ||||||||
| FaxNumber: | 2604324969 | ||||||||
| Practice Location | |||||||||
| Address1: | 7900 W JEFFERSON BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604321568 | ||||||||
| FaxNumber: | 2604324969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 07/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | SCHAEFER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2604357898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 100081420 | 05 | IN | MEDICAID | CA8912 | 01 | IN | MEDICARE RAILROAD | OTHER | 0753475 | 05 | OH | MEDICAID | 0787251 | 05 | OH | MEDICAID |