Provider Demographics
NPI:1790875706
Name:INDIANA MRI, LLC
Entity Type:Organization
Organization Name:INDIANA MRI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-336-0056
Mailing Address - Street 1:3900 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7393
Mailing Address - Country:US
Mailing Address - Phone:812-336-0056
Mailing Address - Fax:812-336-0059
Practice Address - Street 1:3802 INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5141
Practice Address - Country:US
Practice Address - Phone:812-331-7727
Practice Address - Fax:812-331-8983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100185020AMedicaid
IN000000221951OtherANTHEM
IN547310Medicare ID - Type Unspecified
IN100185020AMedicaid