Provider Demographics
NPI:1265572838
Name:PRAIRIE CREEK RADIOLOGY,INC
Entity type:Organization
Organization Name:PRAIRIE CREEK RADIOLOGY,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FAROUK
Authorized Official - Middle Name:E
Authorized Official - Last Name:MERCHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-234-4642
Mailing Address - Street 1:PO BOX 2125
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2125
Mailing Address - Country:US
Mailing Address - Phone:812-234-8261
Mailing Address - Fax:812-234-8262
Practice Address - Street 1:3901 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5709
Practice Address - Country:US
Practice Address - Phone:812-234-8261
Practice Address - Fax:812-234-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031856A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000242179OtherBLUE CROSS/BLUE SHIELD
IN000000242179OtherBLUE CROSS/BLUE SHIELD