Basic Information
| Provider Information | |||||||||
| NPI: | 1801895081 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARION GENERAL RADIOLOGY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 N BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469522542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 441 N WABASH AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469522612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | DEAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8002888325 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100282670B | 05 | IN | MEDICAID | 000000101047 | 01 | IN | BC BS | OTHER | 100282670C | 05 | IN | MEDICAID | 100282670A | 05 | IN | MEDICAID | 100282670D | 05 | IN | MEDICAID |