Healthcare Provider Details

I. General information

NPI: 1386384360
Provider Name (Legal Business Name): PREMIER MEDICAL IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 01/08/2024
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 MILLER DR STE 113B
PLYMOUTH IN
46563-8091
US

IV. Provider business mailing address

PO BOX 338
LA FONTAINE IN
46940-0338
US

V. Phone/Fax

Practice location:
  • Phone: 574-941-1090
  • Fax: 574-941-1095
Mailing address:
  • Phone: 765-228-4660
  • Fax: 765-847-4343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: GARDNER BARTROM
Title or Position: PRESIDENT
Credential:
Phone: 765-228-4660