Basic Information
Provider Information | |||||||||
NPI: | 1154306124 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WELLS | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5901 TECHNOLOGY CENTER DR | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462786013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3173285050 | ||||||||
FaxNumber: | 3177159965 | ||||||||
Practice Location | |||||||||
Address1: | 5901 TECHNOLOGY CENTER DR | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462786013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3173285050 | ||||||||
FaxNumber: | 3177159965 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2005 | ||||||||
LastUpdateDate: | 06/25/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01039309A | IN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 000000492369 | 01 | IN | ANTHEM 203778927 | OTHER | 000000082130 | 01 | IN | ANTHEM-351158723 | OTHER | 002391 | 01 | IN | SIHO-352047427 | OTHER | 300092225 | 01 | IN | RR MEDICARE-352047427 | OTHER | 000000093035 | 01 | IN | ANTHEM-352047427 | OTHER | 052995 | 01 | IN | HEALTH ALLIANCE-351158723 | OTHER | 100218850 | 05 | IN |   | MEDICAID | 300100887 | 01 | IN | RR MEDICARE-351158723 | OTHER | 071706 | 01 | IN | HEALTH ALLIANCE-352047427 | OTHER | Q0084714 | 01 | IN | CMOSHO351158723&352047427 | OTHER | 005570 | 01 | IN | SIHO-351158723 | OTHER |