MEDICARE: INDIANA MRI OF LAFAYETTE 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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669475687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA MRI OF LAFAYETTE LLC

Provider Business Mailing Address
First Line	:	130 PROFESSIONAL CT
Second Line	:	STE C
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-5153
Country	:	US
Telephone Number	:	765-449-7984
Fax Number	:	765-449-9791

Provider Business Practice Location Address
First Line	:	130 PROFESSIONAL CT
Second Line	:	STE C
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-5153
Country	:	US
Telephone Number	:	765-449-7984
Fax Number	:	765-449-9791

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MRS. MICHELLE DOUGLAS
Credential	:
Telephone Number	:	502-403-1401

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	06/12/2008

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