Healthcare Provider Details

I. General information

NPI: 1487706818
Provider Name (Legal Business Name): MEDICAL IMAGING PROFESSIONALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 W BOULEVARD
KOKOMO IN
46902-6079
US

IV. Provider business mailing address

2008 W BOULEVARD
KOKOMO IN
46902-6079
US

V. Phone/Fax

Practice location:
  • Phone: 765-454-9729
  • Fax:
Mailing address:
  • Phone: 765-454-9729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: TODD REYBURN
Title or Position: VP
Credential: MD
Phone: 765-454-9729