Provider Demographics
NPI: | 1760638241 |
---|---|
Name: | MID MICHIGAN DIAGNOSTIC CORP |
Entity Type: | Organization |
Organization Name: | MID MICHIGAN DIAGNOSTIC CORP |
Other - Org Name: | MID MICHIGAN DIAGNOSTICS |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | ZAKWAN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ABOUDANE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 810-742-8770 |
Mailing Address - Street 1: | 1513 S CENTER RD |
Mailing Address - Street 2: | |
Mailing Address - City: | BURTON |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48509-1728 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 810-742-8770 |
Mailing Address - Fax: | 810-742-8772 |
Practice Address - Street 1: | 3400 FLECKENSTEIN RD |
Practice Address - Street 2: | SUITE D |
Practice Address - City: | FLINT |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48507-3043 |
Practice Address - Country: | US |
Practice Address - Phone: | 810-742-8770 |
Practice Address - Fax: | 810-742-8772 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-08-15 |
Last Update Date: | 2009-04-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Single Specialty |