Provider Demographics
NPI:1013070135
Name:MCNICHOLS XRAY CLINIC PC
Entity Type:Organization
Organization Name:MCNICHOLS XRAY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DALESSANDRO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-881-2257
Mailing Address - Street 1:PO BOX 1123
Mailing Address - Street 2:ANESTHESIA BUSINESS CONSULTANTS LLC 774 W MICHIGAN AVE
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-9923
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:
Practice Address - Street 1:21230 DEQUINDRE ROAD
Practice Address - Street 2:SOUTHEAST MICHIGAN SURGICAL HOSPITAL
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091
Practice Address - Country:US
Practice Address - Phone:586-427-1000
Practice Address - Fax:586-759-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI46122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E31621Medicare UPIN
OE04588001Medicare ID - Type Unspecified