Provider Demographics
NPI:1033112990
Name:ADVANCED IMAGING CENTER LLC
Entity Type:Organization
Organization Name:ADVANCED IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHODHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-864-2900
Mailing Address - Street 1:7860 BURR ST
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375
Mailing Address - Country:US
Mailing Address - Phone:219-864-2900
Mailing Address - Fax:219-864-2910
Practice Address - Street 1:7860 BURR ST
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375
Practice Address - Country:US
Practice Address - Phone:219-864-2900
Practice Address - Fax:219-864-2910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1996061345261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200169610Medicaid
IN876240Medicare PIN