Provider Demographics
NPI:1578557815
Name:RADIOLOGY, INC
Entity Type:Organization
Organization Name:RADIOLOGY, INC
Other - Org Name:RADIOLOGY, P.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLOBYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-258-1100
Mailing Address - Street 1:620 W EDISON RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-2784
Mailing Address - Country:US
Mailing Address - Phone:574-258-1100
Mailing Address - Fax:574-258-1101
Practice Address - Street 1:620 W EDISON RD
Practice Address - Street 2:SUITE 110
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2784
Practice Address - Country:US
Practice Address - Phone:574-258-1100
Practice Address - Fax:574-258-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100220290Medicaid
IN100220290Medicaid