Provider Demographics
NPI:1780761486
Name:BALD MOUNTAIN DIAGNOSTIC IMAGING
Entity type:Organization
Organization Name:BALD MOUNTAIN DIAGNOSTIC IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-814-7800
Mailing Address - Street 1:1375 S LAPEER RD
Mailing Address - Street 2:STE 104
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1421
Mailing Address - Country:US
Mailing Address - Phone:248-814-7800
Mailing Address - Fax:248-814-7801
Practice Address - Street 1:1375 S LAPEER RD
Practice Address - Street 2:STE 104
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1421
Practice Address - Country:US
Practice Address - Phone:248-814-7800
Practice Address - Fax:248-814-7801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID