Provider Demographics
NPI:1164607040
Name:SE RADIOLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:SE RADIOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ASHOK
Authorized Official - Middle Name:B
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-326-5030
Mailing Address - Street 1:4000 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1715
Mailing Address - Country:US
Mailing Address - Phone:734-326-5030
Mailing Address - Fax:
Practice Address - Street 1:4491 VENOY RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2530
Practice Address - Country:US
Practice Address - Phone:734-326-5030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI300H276180OtherBCBS OF MICHIGAN
MICE4307OtherRR MEDICARED
MI0H26194Medicare PIN