Provider Demographics
NPI:1023187374
Name:MCGH COMPREHENSIVE BREAST SCREENING CENTER LLC
Entity Type:Organization
Organization Name:MCGH COMPREHENSIVE BREAST SCREENING CENTER LLC
Other - Org Name:MCRMC COMPREHENSIVE BREAST HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF TREASURY
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LISTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-741-4156
Mailing Address - Street 1:43900 GARFIELD RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1128
Mailing Address - Country:US
Mailing Address - Phone:586-412-5150
Mailing Address - Fax:586-412-5165
Practice Address - Street 1:43900 GARFIELD RD
Practice Address - Street 2:SUITE 202
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1128
Practice Address - Country:US
Practice Address - Phone:586-412-5150
Practice Address - Fax:586-412-5165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4458682Medicaid
MI4458691Medicaid
MI4458726Medicaid
MI4458682Medicaid
0N78930Medicare PIN