Provider Demographics
NPI:1326042235
Name:WAYNE MACOMB DIAGNOSTIC IMAGING CENTER INC
Entity Type:Organization
Organization Name:WAYNE MACOMB DIAGNOSTIC IMAGING CENTER INC
Other - Org Name:WAYNE MACOMB MRI CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUPAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-435-2031
Mailing Address - Street 1:18245 E 10 MILE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-5807
Mailing Address - Country:US
Mailing Address - Phone:586-775-6400
Mailing Address - Fax:586-498-1559
Practice Address - Street 1:8690 RELIABLE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60686-0001
Practice Address - Country:US
Practice Address - Phone:586-775-6400
Practice Address - Fax:586-498-1559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2085R0202X2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000000005320OtherCAPE MEDICAL
MIP42884OtherBLUE CARE NETWORK
MI104972OtherPREFERRED CHOICES
MI1207380001OtherWELLNESS PLAN
MI8331930OtherAETNA PPO
MI70097BOtherHEALTH ALLIANCE PLAN
MI148899OtherGREAT LAKES HEALTH PLAN
MI300E06144OtherBLUE CROSS
MIRA820051OtherM CARE
MIM015025OtherCHAMPUS-TRICARE
MI0525947OtherAETNA HMO
MI1207380001OtherWELLNESS PLAN