Provider Demographics
NPI:1235246109
Name:SONOGRAPHIC IMAGES, INC
Entity Type:Organization
Organization Name:SONOGRAPHIC IMAGES, INC
Other - Org Name:SONOGRAPHIC IMAGES, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:219-836-4702
Mailing Address - Street 1:1021 W 5TH AVE
Mailing Address - Street 2:221
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1703
Mailing Address - Country:US
Mailing Address - Phone:219-836-4702
Mailing Address - Fax:708-808-9755
Practice Address - Street 1:1021 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1703
Practice Address - Country:US
Practice Address - Phone:219-836-4702
Practice Address - Fax:708-808-9755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1567652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100022050AMedicaid
IL0001618757OtherBCBS
IN100022050AMedicaid
IN100022050AMedicaid
L73609Medicare UPIN
IN071000Medicare ID - Type Unspecified