Basic Information
| Provider Information | |||||||||
| NPI: | 1891193314 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEDICAL IMAGING INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 OHIO BLVD | ||||||||
| Address2: | STE 127 | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478032239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122348190 | ||||||||
| FaxNumber: | 8122348262 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 N SECTION ST | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122684311 | ||||||||
| FaxNumber: | 8122682657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2014 | ||||||||
| LastUpdateDate: | 03/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2623916757 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 02003965A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 201274190A | 05 | IN | MEDICAID |