Provider Demographics
NPI:1831790864
Name:MY MOBILE DIAGNOSTICS IDTF LLC
Entity type:Organization
Organization Name:MY MOBILE DIAGNOSTICS IDTF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-670-6635
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-0586
Mailing Address - Country:US
Mailing Address - Phone:765-969-7841
Mailing Address - Fax:317-552-1666
Practice Address - Street 1:429 E VERMONT ST STE 110
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3685
Practice Address - Country:US
Practice Address - Phone:317-912-1548
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory