Basic Information
| Provider Information | |||||||||
| NPI: | 1447259338 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST RADIOLOGY NETWORK, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHWEST RADIOLOGIST PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| 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: | 07/21/2005 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILGUS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3173285050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 50000088 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100402910 | 05 | IN | MEDICAID |