Provider Demographics
NPI:1821571399
Name:PREMIER MEDICAL IMAGING LLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE-DEE
Authorized Official - Middle Name:GARDNER
Authorized Official - Last Name:BARTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-228-4660
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:LA FONTAINE
Mailing Address - State:IN
Mailing Address - Zip Code:46940-0338
Mailing Address - Country:US
Mailing Address - Phone:765-228-4660
Mailing Address - Fax:
Practice Address - Street 1:2855 MILLER DR STE 113
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8091
Practice Address - Country:US
Practice Address - Phone:765-228-4660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-11
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Multi-Specialty
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
No2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300021965Medicaid