Provider Demographics
NPI:1689733503
Name:ASSOCIATED RADIOLOGISTS OF CLARKSTON PLC
Entity Type:Organization
Organization Name:ASSOCIATED RADIOLOGISTS OF CLARKSTON PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-625-2621
Mailing Address - Street 1:6770 DIXIE HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2089
Mailing Address - Country:US
Mailing Address - Phone:248-625-2621
Mailing Address - Fax:248-922-5973
Practice Address - Street 1:7210 ORTONVILLE RD. STE 211
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010452082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5187744Medicaid
MI4996896Medicaid
MI5187744Medicaid