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Physicians Radiology Diagnostic Radiology

Provider NPI: 1639159601

Provider Information:
Gender: M
Not Sole Proprietor

Practice Location:
620 W EDISON RD STE 110 MISHAWAKA, IN 46545-2784 US
Tel: 574-258-1100  Fax: 574-258-1101

Business Mailing Address:
620 W EDISON RD STE 110 MISHAWAKA, IN 46545-2784 US
Tel: 574-258-1100  Fax: 574-258-1101

NPI Information:
NPI: 1639159601
Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
Diagnostic Radiology

Other Provider Identifiers:


American Medical Association 2012 taxonomy code information

Code: 2085R0202X





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