Provider Demographics
NPI:1376889568
Name:INDIANA UNIVERSITY RADIOLOGY ASSOCIATES INC
Entity Type:Organization
Organization Name:INDIANA UNIVERSITY RADIOLOGY ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY, TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LUCKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-472-4565
Mailing Address - Street 1:714 N SENATE AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3763
Mailing Address - Country:US
Mailing Address - Phone:317-962-4836
Mailing Address - Fax:317-962-4391
Practice Address - Street 1:250 N SHADELAND AVE
Practice Address - Street 2:STE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4959
Practice Address - Country:US
Practice Address - Phone:317-962-4836
Practice Address - Fax:317-962-4391
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IU RADIOLOGY ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-17
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010577122300000X, 1223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201129790Medicaid
IN959090Medicare PIN