Provider Demographics
NPI:1891840062
Name:LAFAYETTE RADIOLOGY LLC
Entity Type:Organization
Organization Name:LAFAYETTE RADIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:MEHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-446-4819
Mailing Address - Street 1:3900 ST FRANCIS WAY
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4925
Mailing Address - Country:US
Mailing Address - Phone:765-446-4819
Mailing Address - Fax:765-466-4959
Practice Address - Street 1:1501 HARTFORD ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2134
Practice Address - Country:US
Practice Address - Phone:765-502-4000
Practice Address - Fax:765-446-4859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDG0872OtherRR MEDICARE
IN200856080Medicaid
IN248640Medicare PIN