Provider Demographics
NPI:1659630879
Name:INDIANA ULTRASOUND LLC
Entity Type:Organization
Organization Name:INDIANA ULTRASOUND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:219-746-6662
Mailing Address - Street 1:2055 W 64TH PL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-3114
Mailing Address - Country:US
Mailing Address - Phone:219-746-6662
Mailing Address - Fax:
Practice Address - Street 1:2055 W 64TH PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-3114
Practice Address - Country:US
Practice Address - Phone:219-746-6662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service