Provider Demographics
NPI:1174787204
Name:INDIANA BREAST CENTER
Entity type:Organization
Organization Name:INDIANA BREAST CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:WOODBURN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:574-271-2558
Mailing Address - Street 1:5363 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-5325
Mailing Address - Country:US
Mailing Address - Phone:219-769-5000
Mailing Address - Fax:
Practice Address - Street 1:5363 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-5325
Practice Address - Country:US
Practice Address - Phone:219-769-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUDAG LLC DBA CANCER TREATMENT GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200397270Medicaid
IN200397270Medicaid