Provider Demographics
NPI:1851459572
Name:TRIAD DIAGNOSTIC TECHNOLOGIES, LLC.
Entity Type:Organization
Organization Name:TRIAD DIAGNOSTIC TECHNOLOGIES, LLC.
Other - Org Name:TRIAD DIAGNOSTICS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAYRAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-421-5420
Mailing Address - Street 1:869 LAKE SHORE RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1274
Mailing Address - Country:US
Mailing Address - Phone:248-421-5420
Mailing Address - Fax:
Practice Address - Street 1:30514 KNIGHTON DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-5929
Practice Address - Country:US
Practice Address - Phone:877-572-3837
Practice Address - Fax:248-319-0354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI310F303370OtherBLUE CROSS BLUE SHIELD