MEDICARE: PREMIER DIAGNOSTIC IMAGING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	XF201098	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023049806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER DIAGNOSTIC IMAGING LLC

Provider Business Mailing Address
First Line	:	135 E MCCALLISTER DR
Second Line	:
City	:	TERRE HAUTE
State	:	IN
Zip	:	47802-4247
Country	:	US
Telephone Number	:	812-478-3900
Fax Number	:	812-478-5868

Provider Business Practice Location Address
First Line	:	135 E MCCALLISTER DR
Second Line	:
City	:	TERRE HAUTE
State	:	IN
Zip	:	47802-4247
Country	:	US
Telephone Number	:	812-478-3900
Fax Number	:	812-478-5868

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. JAYAPRAKASARAO KONIJETI
Credential	:	M.D.
Telephone Number	:	812-478-3900

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	11/02/2007

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