Provider Demographics
NPI:1336114503
Name:LIFETEST MICHIGAN LLC
Entity Type:Organization
Organization Name:LIFETEST MICHIGAN LLC
Other - Org Name:EBT HEART & BODY IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-733-6780
Mailing Address - Street 1:G3239 BEECHER RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532
Mailing Address - Country:US
Mailing Address - Phone:810-733-6780
Mailing Address - Fax:810-733-8871
Practice Address - Street 1:26400 W 12 MILE RD
Practice Address - Street 2:SUITE 114
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034
Practice Address - Country:US
Practice Address - Phone:248-358-3223
Practice Address - Fax:248-358-3218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
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
MI0F31831OtherBCBSM GROUP NUMBER
MI0N44150Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER