Provider Demographics
NPI:1891881066
Name:EAST BELTLINE IMAGING PLC
Entity Type:Organization
Organization Name:EAST BELTLINE IMAGING PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TARATUTA
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:616-456-9553
Mailing Address - Street 1:3210 EAGLE RUN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7051
Mailing Address - Country:US
Mailing Address - Phone:616-301-7500
Mailing Address - Fax:616-301-3606
Practice Address - Street 1:3210 EAGLE RUN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7051
Practice Address - Country:US
Practice Address - Phone:616-301-7500
Practice Address - Fax:616-301-3606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIHS062163174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI32885OtherPRIORITY HEALTH
MI700D115760OtherBLUE SHIELD
MI=========OtherTAX ID NUMBER