1326042235 NPI number — WAYNE MACOMB DIAGNOSTIC IMAGING CENTER INC

Table of content: (NPI 1326042235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326042235 NPI number — WAYNE MACOMB DIAGNOSTIC IMAGING CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNE MACOMB DIAGNOSTIC IMAGING CENTER INC
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:
WAYNE MACOMB MRI CENTER
Provider Other Organization Name Type Code:
3
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:
1326042235
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18245 E 10 MILE RD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48066-5807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-775-6400
Provider Business Mailing Address Fax Number:
586-498-1559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8690 RELIABLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60686-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-775-6400
Provider Business Practice Location Address Fax Number:
586-498-1559
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ZUPAN
Authorized Official First Name:
CAROLE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
586-435-2031

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  2085R0202X , 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: 000000005320 . This is a "CAPE MEDICAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P42884 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104972 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1207380001 . This is a "WELLNESS PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 8331930 . This is a "AETNA PPO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 70097B . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 148899 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 300E06144 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: RA820051 . This is a "M CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: M015025 . This is a "CHAMPUS-TRICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0525947 . This is a "AETNA HMO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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