Provider Demographics
NPI:1104831783
Name:MECOSTA COUNTY RADIOLOGY, LLC
Entity Type:Organization
Organization Name:MECOSTA COUNTY RADIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BLASE
Authorized Official - Middle Name:
Authorized Official - Last Name:VITELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-592-4212
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:ATTN: LYNDA THOMPSON
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:734-677-7400
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:605 OAK ST
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2048
Practice Address - Country:US
Practice Address - Phone:231-592-4212
Practice Address - Fax:231-592-4343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDB9242OtherRR MEDICARE
MI=========OtherEIN #
MI=========OtherEIN #