Provider Demographics
NPI:1730225848
Name:MEMORIAL LIGHTHOUSE IMAGING LLC
Entity type:Organization
Organization Name:MEMORIAL LIGHTHOUSE IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:A
Authorized Official - Last Name:MIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-258-1100
Mailing Address - Street 1:620 W EDISON RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-2784
Mailing Address - Country:US
Mailing Address - Phone:574-258-1100
Mailing Address - Fax:574-258-1101
Practice Address - Street 1:919 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3112
Practice Address - Country:US
Practice Address - Phone:574-288-4486
Practice Address - Fax:574-258-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
Not Answered2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
Not Answered2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty