Provider Demographics
NPI:1588669667
Name:IMA INC LABORATORY
Entity Type:Organization
Organization Name:IMA INC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF LAB
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:F
Authorized Official - Last Name:HRISOMALOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-355-3406
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-0550
Mailing Address - Country:US
Mailing Address - Phone:812-331-3406
Mailing Address - Fax:812-334-0536
Practice Address - Street 1:550 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3239
Practice Address - Country:US
Practice Address - Phone:812-331-3406
Practice Address - Fax:812-334-0536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15D0360681291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN549380Medicare ID - Type Unspecified