Basic Information
| Provider Information | |||||||||
| NPI: | 1114978350 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST VINCENT NORTHWEST RADIOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 TECHNOLOGY CENTER DR | ||||||||
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| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462786013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173285050 | ||||||||
| FaxNumber: | 3177159965 | ||||||||
| Practice Location | |||||||||
| Address1: | 11201 USA PKWY | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460379202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179138910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 06/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | WILGUS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3173285050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200182900 | 05 | IN | MEDICAID |