Provider Demographics
NPI:1972829372
Name:ELEVATED DIAGNOSTIC IMAGING AND PAIN MANAGEMENT CENTER LLC
Entity Type:Organization
Organization Name:ELEVATED DIAGNOSTIC IMAGING AND PAIN MANAGEMENT CENTER LLC
Other - Org Name:EDI LLC.
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:317-504-1665
Mailing Address - Street 1:5045 BROOKSTONE LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-5420
Mailing Address - Country:US
Mailing Address - Phone:317-504-1665
Mailing Address - Fax:
Practice Address - Street 1:1642 OLIVE BRANCH PARK LN
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-6447
Practice Address - Country:US
Practice Address - Phone:317-504-1665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QM1200X261QM1200X
IN261QM1300X261QM1300X
IN261QP1100X261QP1100X
IN261QP3300X261QP3300X
IN261QR0200X261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology