Provider Demographics
NPI:1669475687
Name:INDIANA MRI OF LAFAYETTE LLC
Entity Type:Organization
Organization Name:INDIANA MRI OF LAFAYETTE LLC
Other - Org Name:OPEN MRI OF LAFAYETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-403-1401
Mailing Address - Street 1:130 PROFESSIONAL CT
Mailing Address - Street 2:STE C
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5153
Mailing Address - Country:US
Mailing Address - Phone:765-449-7984
Mailing Address - Fax:765-449-9791
Practice Address - Street 1:130 PROFESSIONAL CT
Practice Address - Street 2:STE C
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5153
Practice Address - Country:US
Practice Address - Phone:765-449-7984
Practice Address - Fax:765-449-9791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200134270Medicaid
189190Medicare PIN