Provider Demographics
NPI:1023049806
Name:PREMIER DIAGNOSTIC IMAGING LLC
Entity type:Organization
Organization Name:PREMIER DIAGNOSTIC IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYAPRAKASARAO
Authorized Official - Middle Name:
Authorized Official - Last Name:KONIJETI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-478-3900
Mailing Address - Street 1:135 E MCCALLISTER DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4247
Mailing Address - Country:US
Mailing Address - Phone:812-478-3900
Mailing Address - Fax:812-478-5868
Practice Address - Street 1:135 E MCCALLISTER DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4247
Practice Address - Country:US
Practice Address - Phone:812-478-3900
Practice Address - Fax:812-478-5868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INXF2010982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200514950Medicaid
IN200514950Medicaid