Provider Demographics
NPI:1336704311
Name:GENESIS MD DIAGNOSTIC IMAGING PC
Entity Type:Organization
Organization Name:GENESIS MD DIAGNOSTIC IMAGING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-581-3255
Mailing Address - Street 1:8560 N SILVERY LN STE 101
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-4516
Mailing Address - Country:US
Mailing Address - Phone:313-581-3255
Mailing Address - Fax:313-581-3755
Practice Address - Street 1:8560 N SILVERY LN STE 101
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-4516
Practice Address - Country:US
Practice Address - Phone:313-581-3255
Practice Address - Fax:313-581-3755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile