MEDICARE: IMAGING DIAGNOSTIC CENTER LIMITED

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	2085R0202X	Diagnostic Radiology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CA8912	OTHER	IN	MEDICARE RAILROAD

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
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871564336
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGING DIAGNOSTIC CENTER LIMITED

Provider Business Mailing Address
First Line	:	6119 W JEFFERSON BLVD
Second Line	:	IMAGING DIAGNOSTIC CENTER
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-3072
Country	:	US
Telephone Number	:	260-432-1568
Fax Number	:	260-432-4969

Provider Business Practice Location Address
First Line	:	7900 W JEFFERSON BLVD STE 101
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4128
Country	:	US
Telephone Number	:	260-432-1568
Fax Number	:	260-432-4969

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. MARK WILLIAM SCHAEFER
Credential	:
Telephone Number	:	260-435-7898

Provider Enumeration Date	:	01/31/2006
Last Update Date	:	07/01/2008

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Directions to “IMAGING DIAGNOSTIC CENTER LIMITED ” Practice Location

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