Provider Demographics
NPI:1639438062
Name:ADVANCED DIAGNOSTIC MEDICAL IMAGING PC
Entity Type:Organization
Organization Name:ADVANCED DIAGNOSTIC MEDICAL IMAGING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:248-593-9780
Mailing Address - Street 1:19891 PARKE LN
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1027
Mailing Address - Country:US
Mailing Address - Phone:734-671-6677
Mailing Address - Fax:
Practice Address - Street 1:19891 PARKE LN
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-1027
Practice Address - Country:US
Practice Address - Phone:734-671-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-04
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010110212085R0202X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty