Provider Demographics
NPI:1982611224
Name:PARK PLAZA RADIOLOGY, INC
Entity Type:Organization
Organization Name:PARK PLAZA RADIOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:APPARAO
Authorized Official - Middle Name:
Authorized Official - Last Name:MUKKAMALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-424-4761
Mailing Address - Street 1:PO BOX 4459
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-4850
Mailing Address - Country:US
Mailing Address - Phone:810-424-4761
Mailing Address - Fax:810-424-4871
Practice Address - Street 1:G 1071 N BALLENGER HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504
Practice Address - Country:US
Practice Address - Phone:810-235-0668
Practice Address - Fax:810-235-8928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031703207U00000X
MI43010425152085N0700X
MI43010315882085R0202X
MI43010341232085R0202X
MI43010570462085R0202X
MI43010346752085R0202X
MI43010377092085R0202X
MI43010469322085R0202X
MI43014069122085R0202X
MI43010371122085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Single Specialty
Not Answered2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B56014OtherBCBS COMMON PROVIDER CODE
MI0B56014Medicare ID - Type UnspecifiedMEDICARE COMMON PROVIDER