Provider Demographics
NPI:1124394895
Name:MOBILERADIOLOGY.ORG, LLC
Entity Type:Organization
Organization Name:MOBILERADIOLOGY.ORG, LLC
Other - Org Name:SOURCE DIAGNOSTICS OF INDIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-645-7822
Mailing Address - Street 1:5275 NAIMAN PKWY
Mailing Address - Street 2:STE E
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-1029
Mailing Address - Country:US
Mailing Address - Phone:440-542-1515
Mailing Address - Fax:
Practice Address - Street 1:13645 MCKINLEY HWY
Practice Address - Street 2:UNIT A
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-7492
Practice Address - Country:US
Practice Address - Phone:574-274-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM300051794Medicare PIN