Healthcare Provider Details

I. General information

NPI: 1376889568
Provider Name (Legal Business Name): INDIANA UNIVERSITY RADIOLOGY ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 N SHADELAND AVE STE 200
INDIANAPOLIS IN
46219-4959
US

IV. Provider business mailing address

714 N SENATE AVE STE 100
INDIANAPOLIS IN
46202-3763
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-4836
  • Fax: 317-962-4391
Mailing address:
  • Phone: 317-962-4836
  • Fax: 317-962-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12010577
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number12010577
License Number StateIN

VIII. Authorized Official

Name: MR. RANDALL J LUCKEY
Title or Position: SECRETARY, TREASURER
Credential:
Phone: 317-472-4565