Provider Demographics
NPI:1235186867
Name:RADIOLOGIC ASSOCIATES OF NORTHWEST INDIANA, PC
Entity Type:Organization
Organization Name:RADIOLOGIC ASSOCIATES OF NORTHWEST INDIANA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ODUM
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:219-464-4891
Mailing Address - Street 1:85 E US HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-8947
Mailing Address - Country:US
Mailing Address - Phone:219-464-4891
Mailing Address - Fax:219-464-1873
Practice Address - Street 1:85 E US HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-8947
Practice Address - Country:US
Practice Address - Phone:219-464-4891
Practice Address - Fax:219-464-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000061A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100225330Medicaid
INCBO346OtherRR MEDICARE
655660OtherMEDICARE PTAN