Provider Demographics
NPI:1629394457
Name:GREAT LAKES MUSCULOSKELETAL ULTRASOUND INC.
Entity Type:Organization
Organization Name:GREAT LAKES MUSCULOSKELETAL ULTRASOUND INC.
Other - Org Name:GREAT LAKES MSK US INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RT R RDMS
Authorized Official - Phone:313-258-6131
Mailing Address - Street 1:6928 COLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1776
Mailing Address - Country:US
Mailing Address - Phone:313-258-6131
Mailing Address - Fax:517-702-2944
Practice Address - Street 1:6928 COLEMAN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1776
Practice Address - Country:US
Practice Address - Phone:313-258-6131
Practice Address - Fax:517-702-2944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI41833261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile