=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558780759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASCOT DIAGNOSTIC SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2014
-----------------------------------------------------
Last Update Date | 04/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5490 BROADWAY
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-1675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-472-1711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5490 BROADWAY
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-1675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-472-1711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF OPERATIONS
-----------------------------------------------------
Name | PRANAVI REDDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-830-3010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------