Provider Demographics
NPI:1184855272
Name:IMA EAST PRIMARY CARE
Entity Type:Organization
Organization Name:IMA EAST PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:RATLIF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-331-3400
Mailing Address - Street 1:550 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:812-355-6900
Mailing Address - Fax:812-355-3251
Practice Address - Street 1:2605 E CREEKS EDGE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8368
Practice Address - Country:US
Practice Address - Phone:812-355-2300
Practice Address - Fax:812-355-3251
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-06
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066805A207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6020150002Medicare NSC