Healthcare Provider Details

I. General information

NPI: 1790875706
Provider Name (Legal Business Name): INDIANA MRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 INDUSTRIAL BLVD SUITE 4
BLOOMINGTON IN
47403-5141
US

IV. Provider business mailing address

3900 S WALNUT ST
BLOOMINGTON IN
47401-7393
US

V. Phone/Fax

Practice location:
  • Phone: 812-331-7727
  • Fax: 812-331-8983
Mailing address:
  • Phone: 812-336-0056
  • Fax: 812-336-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OWEN LAUER
Title or Position: MANAGING MEMBER
Credential:
Phone: 812-336-0056