=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962206771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIANA MOBILE RADIOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2025
-----------------------------------------------------
Last Update Date | 04/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3905 VINCENNES RD STE 303
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46268-3030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-797-1133
-----------------------------------------------------
Fax | 317-471-3508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3905 VINCENNES RD STE 303
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46268-3030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-827-5058
-----------------------------------------------------
Fax | 317-471-3508
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. JEAN PIERRE PRISO
-----------------------------------------------------
Credential | RT(R)
-----------------------------------------------------
Telephone | 317-797-1133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------