Provider Demographics
NPI:1043220205
Name:BEAUMONT SPECIAL RADIOLOGICAL PROCEDURES
Entity Type:Organization
Organization Name:BEAUMONT SPECIAL RADIOLOGICAL PROCEDURES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF RAD DEPT/PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MEZWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-898-6064
Mailing Address - Street 1:PO BOX 64011
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48264-0001
Mailing Address - Country:US
Mailing Address - Phone:586-412-4000
Mailing Address - Fax:586-412-4102
Practice Address - Street 1:3601 W THIRTEEN MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-898-6064
Practice Address - Fax:248-898-5490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOH26354Medicare ID - Type Unspecified