Provider Demographics
NPI:1215319751
Name:BOOMGARDEN, ERICH (MD)
Entity type:Individual
Prefix:
First Name:ERICH
Middle Name:
Last Name:BOOMGARDEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:550 UNIVERSITY BLVD
Mailing Address - Street 2:ROOM 0641 - DEPARTMENT OF RADIOLOGY AND IMAGING SCIENCE
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5149
Mailing Address - Country:US
Mailing Address - Phone:317-948-2449
Mailing Address - Fax:317-948-2803
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:ROOM 0641 - DEPARTMENT OF RADIOLOGY AND IMAGING SCIENCE
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-948-2449
Practice Address - Fax:317-948-2803
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-21
Last Update Date:2016-06-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO20150171462085R0202X
IN11018610A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology