Provider Demographics
NPI:1477515278
Name:DIAGNOSTIC IMAGING OF WEST BRANCH PC
Entity Type:Organization
Organization Name:DIAGNOSTIC IMAGING OF WEST BRANCH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WACKERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-893-6573
Mailing Address - Street 1:302 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708
Mailing Address - Country:US
Mailing Address - Phone:989-893-6573
Mailing Address - Fax:989-922-4737
Practice Address - Street 1:2463 S M-30
Practice Address - Street 2:335 E HOUGHTON AVE
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661
Practice Address - Country:US
Practice Address - Phone:989-343-3141
Practice Address - Fax:989-343-3136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P113493OtherBCBS MI
P113493OtherBCBS MI
MI0N40860Medicare ID - Type Unspecified