Basic Information
| Provider Information | |||||||||
| NPI: | 1205879988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOGNANNO | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9998 CROSSPOINT BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178068260 | ||||||||
| FaxNumber: | 3178068296 | ||||||||
| Practice Location | |||||||||
| Address1: | 9998 CROSSPOINT BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178068260 | ||||||||
| FaxNumber: | 3178068296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 1035155A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000091495 | 01 | IN | ANTHEM | OTHER | 100320950 | 05 | IN | MEDICAID |