Provider Demographics
NPI:1871564336
Name:IMAGING DIAGNOSTIC CENTER LIMITED
Entity type:Organization
Organization Name:IMAGING DIAGNOSTIC CENTER LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-435-7898
Mailing Address - Street 1:6119 W JEFFERSON BLVD
Mailing Address - Street 2:IMAGING DIAGNOSTIC CENTER
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-3072
Mailing Address - Country:US
Mailing Address - Phone:260-432-1568
Mailing Address - Fax:260-432-4969
Practice Address - Street 1:7900 W JEFFERSON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-432-1568
Practice Address - Fax:260-432-4969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100081420Medicaid
INCA8912OtherMEDICARE RAILROAD
OH0753475Medicaid
OH0787251Medicaid
OH0787251Medicaid
INCA8912Medicare PIN