Provider Demographics
NPI:1770740581
Name:MID-MICHIGAN RADIOLOGY ASSOCIATES, PC
Entity type:Organization
Organization Name:MID-MICHIGAN RADIOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHANNES
Authorized Official - Middle Name:
Authorized Official - Last Name:BUITEWEG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-773-2018
Mailing Address - Street 1:PO BOX 30516
Mailing Address - Street 2:DEPT 6086
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-8016
Mailing Address - Country:US
Mailing Address - Phone:989-466-3342
Mailing Address - Fax:989-466-7250
Practice Address - Street 1:300 WARWICK
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1014
Practice Address - Country:US
Practice Address - Phone:989-466-3342
Practice Address - Fax:989-466-7250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI300B960080OtherBCBS OF MICHIGAN
MI0B96008Medicare PIN