Provider Demographics
NPI:1972586717
Name:GREAT LAKES MRI OF MICHIGAN LLC
Entity Type:Organization
Organization Name:GREAT LAKES MRI OF MICHIGAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARBONIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-427-7226
Mailing Address - Street 1:27301 SCHOENHERR RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-6649
Mailing Address - Country:US
Mailing Address - Phone:586-427-7226
Mailing Address - Fax:
Practice Address - Street 1:27301 SCHOENHERR RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6649
Practice Address - Country:US
Practice Address - Phone:586-427-7226
Practice Address - Fax:586-427-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-25
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N49170Medicare ID - Type Unspecified