1770740581 NPI number — MID-MICHIGAN RADIOLOGY ASSOCIATES, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770740581 NPI number — MID-MICHIGAN RADIOLOGY ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-MICHIGAN 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:
1770740581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30516
Provider Second Line Business Mailing Address:
DEPT 6086
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48909-8016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-466-3342
Provider Business Mailing Address Fax Number:
989-466-7250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 WARWICK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALMA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48801-1014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-466-3342
Provider Business Practice Location Address Fax Number:
989-466-7250
Provider Enumeration Date:
05/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BUITEWEG
Authorized Official First Name:
JOHANNES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
989-773-2018

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: 300B960080 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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