Provider Demographics
NPI:1942263736
Name:LIVONIA RADIOLOGY GROUP PC
Entity Type:Organization
Organization Name:LIVONIA RADIOLOGY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NADER
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOHTADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-591-1171
Mailing Address - Street 1:14555 LEVAN
Mailing Address - Street 2:STE 310
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5085
Mailing Address - Country:US
Mailing Address - Phone:734-591-1171
Mailing Address - Fax:734-591-1656
Practice Address - Street 1:36475 5 MILE
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1971
Practice Address - Country:US
Practice Address - Phone:734-655-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3516119Medicaid
B49408Medicare UPIN