1124073762 NPI number — BOTSFORD MEDICAL IMAGING, PC

Table of content: (NPI 1124073762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124073762 NPI number — BOTSFORD MEDICAL IMAGING, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOTSFORD MEDICAL IMAGING, 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:
1124073762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28050 GRAND RIVER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48336-5919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-471-8371
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28050 GRAND RIVER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48336-5919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-471-8371
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCKNIGHT
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
HEAD OF GROUP
Authorized Official Telephone Number:
248-471-8371

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 005741 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4468121 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 506640 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: XX25381 . This is a "HEALTHPLUS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0F31877 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 025821 . This is a "MIDWEST HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 136309000 . This is a "US DEPT OF LABOR WORKCOMP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 506640 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 600970 . This is a "ULTIMED" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: RA630003 . This is a "M-CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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