Provider Demographics
NPI:1225219652
Name:MED IMAGING OF INDIANA, LLC
Entity Type:Organization
Organization Name:MED IMAGING OF INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-786-0522
Mailing Address - Street 1:6948 ALCOA RD
Mailing Address - Street 2:SUITE K
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-9726
Mailing Address - Country:US
Mailing Address - Phone:501-778-9729
Mailing Address - Fax:501-776-2695
Practice Address - Street 1:2045 RAMA DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1710
Practice Address - Country:US
Practice Address - Phone:317-871-2790
Practice Address - Fax:317-871-2792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200908550AMedicaid