MEDICARE: INSTITUTE OF DIAGNOSTIC IMAGING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04128	OTHER	NE	BCBS
2	1015837	OTHER	NE	GREAT WEST

General Provider Information

NPI Number	:	1144331141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSTITUTE OF DIAGNOSTIC IMAGING, LLC

Provider Business Mailing Address
First Line	:	2829 UNIVERSITY DR S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58103-6050
Country	:	US
Telephone Number	:	701-297-0305
Fax Number	:	701-235-4847

Provider Business Practice Location Address
First Line	:	11819 MIRACLE HILLS DR
Second Line	:	SUITE 101
City	:	OMAHA
State	:	NE
Zip	:	68154-4428
Country	:	US
Telephone Number	:	402-898-3630
Fax Number	:	402-898-3635

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL J HOFER SR.
Credential	:
Telephone Number	:	701-297-0305

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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