MEDICARE: EAST BELTLINE IMAGING PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center
2	174400000X	Specialist	HS062163	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	700D115760	OTHER	MI	BLUE SHIELD
2	32885	OTHER	MI	PRIORITY HEALTH

General Provider Information

NPI Number	:	1891881066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST BELTLINE IMAGING PLC

Provider Business Mailing Address
First Line	:	3210 EAGLE RUN DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-7051
Country	:	US
Telephone Number	:	616-301-7500
Fax Number	:	616-301-3606

Provider Business Practice Location Address
First Line	:	3210 EAGLE RUN DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-7051
Country	:	US
Telephone Number	:	616-301-7500
Fax Number	:	616-301-3606

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MEGAN TARATUTA
Credential	:	PAC
Telephone Number	:	616-456-9553

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	05/14/2024

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Directions to “EAST BELTLINE IMAGING PLC ” Practice Location

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