Provider Demographics
NPI:1134178148
Name:SOUTHLAKE MRI & DIAGNOSTIC CENTER LLC
Entity type:Organization
Organization Name:SOUTHLAKE MRI & DIAGNOSTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:RAMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOPRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-736-2700
Mailing Address - Street 1:108 E 90TH DR
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7160
Mailing Address - Country:US
Mailing Address - Phone:219-795-1801
Mailing Address - Fax:219-795-1802
Practice Address - Street 1:108 E 90TH DR
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7160
Practice Address - Country:US
Practice Address - Phone:219-795-1801
Practice Address - Fax:219-795-1802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085B0100X
INXM017160261QM1200X
INXF200740261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200500590Medicaid
IN221820Medicare ID - Type UnspecifiedGROUP NUMBER