Healthcare Provider Details

I. General information

NPI: 1649543141
Provider Name (Legal Business Name): INNERVISION ADVANCED MEDICAL IMAGING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 S CREASY LANE SUITE 130
LAFAYETTE IN
47905-7433
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-447-7447
  • Fax: 765-446-5317
Mailing address:
  • Phone: 765-449-2732
  • Fax: 765-446-5317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTHA K MILLER
Title or Position: DIRECTOR OF BILLING
Credential:
Phone: 765-446-5417