Provider Demographics
NPI:1245252592
Name:EAST CENTRAL INDIANA VASCULAR LAB LLC
Entity type:Organization
Organization Name:EAST CENTRAL INDIANA VASCULAR LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIADES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-284-7703
Mailing Address - Street 1:1812 W ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2243
Mailing Address - Country:US
Mailing Address - Phone:765-284-7703
Mailing Address - Fax:765-284-6838
Practice Address - Street 1:1812 W ROYALE DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2243
Practice Address - Country:US
Practice Address - Phone:765-284-7703
Practice Address - Fax:765-284-6838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201040080Medicaid
IN205870Medicare PIN