1063634509 NPI number — NORTHERN RADIOLOGY ASSOCIATES PC

Table of content: (NPI 1063634509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063634509 NPI number — NORTHERN RADIOLOGY ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN RADIOLOGY ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063634509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1096 LACVUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOYNE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-677-7400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14700 LAKE SHORE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLEVOIX
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-547-4024
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARLAN
Authorized Official First Name:
CARL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
800-764-7297

Provider Taxonomy Codes

  • Taxonomy code: 2085B0100X , with the licence number:  CH008593 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3151500034 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0A510270 . This is a "BCBS GROUP PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 300086775 . This is a "RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 300086775 . This is a "MEDICARE RR PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3450062 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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