Provider Demographics
NPI:1235278961
Name:ADVANCED DIAGNOSTIC IMAGING PC
Entity Type:Organization
Organization Name:ADVANCED DIAGNOSTIC IMAGING PC
Other - Org Name:WABASH DIAGNOSTIC IMAGING, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-475-0765
Mailing Address - Street 1:1120 PROFESSIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-8000
Mailing Address - Country:US
Mailing Address - Phone:812-471-7086
Mailing Address - Fax:812-471-3381
Practice Address - Street 1:328 N 2ND ST STE 101
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1353
Practice Address - Country:US
Practice Address - Phone:812-882-8252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200181650AMedicaid
IN200181650AMedicaid