Healthcare Provider Details

I. General information

NPI: 1326042235
Provider Name (Legal Business Name): WAYNE MACOMB DIAGNOSTIC IMAGING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8690 RELIABLE
CHICAGO IL
60686-0001
US

IV. Provider business mailing address

18245 E 10 MILE RD STE 100
ROSEVILLE MI
48066-5807
US

V. Phone/Fax

Practice location:
  • Phone: 586-775-6400
  • Fax: 586-498-1559
Mailing address:
  • Phone: 586-775-6400
  • Fax: 586-498-1559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2085R0202X
License Number StateMI

VIII. Authorized Official

Name: MRS. CAROLE ZUPAN
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 586-435-2031