Provider Demographics
NPI:1568460830
Name:HEARTLAND DIAGNOSTIC IMAGING
Entity Type:Organization
Organization Name:HEARTLAND DIAGNOSTIC IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-533-2141
Mailing Address - Street 1:PO BOX 753
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46527-0753
Mailing Address - Country:US
Mailing Address - Phone:937-323-5400
Mailing Address - Fax:
Practice Address - Street 1:200 HIGH PARK AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4810
Practice Address - Country:US
Practice Address - Phone:574-533-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000315548OtherBC BS
INDA4142OtherRAILROAD MEDICARE
INDA4142OtherRAILROAD MEDICARE