Provider Demographics
NPI:1760404891
Name:GRAND TRAVERSE RADIOLOGISTS PC
Entity Type:Organization
Organization Name:GRAND TRAVERSE RADIOLOGISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-0497
Mailing Address - Street 1:PO BOX 30516
Mailing Address - Street 2:DEPT. 9516
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-8016
Mailing Address - Country:US
Mailing Address - Phone:800-475-6112
Mailing Address - Fax:423-826-1286
Practice Address - Street 1:1105 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-935-0497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI134232100OtherUS DEPT. OF LABOR
MI27837OtherCOMMUNITY CHOICE MI
MI53556AOtherHEALTH ALLIANCE PLAN
MI008081OtherMIDWEST HEALTH PLAN
MIXX00308OtherHEALTHPLUS OF MI
MI104756OtherCARE CHOICES
WI12088500Medicaid
MI10399OtherM-CARE
MI104756OtherPREFERRED CHOICES
MICA3471OtherRAILROAD MEDICARE
MIN16010OtherNORTHMED HMO
MI0B87605OtherBLUE CROSS BLUE SHIELD
MI280047OtherFEDERAL BLACK LUNG
MI4055OtherPRIORITY HEALTH
MI803002OtherCOMMUNITY CARE PLAN
MI104756OtherPREFERRED CHOICES
MI0B86004Medicare PIN