Healthcare Provider Details

I. General information

NPI: 1639438062
Provider Name (Legal Business Name): ADVANCED DIAGNOSTIC MEDICAL IMAGING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19891 PARKE LN
GROSSE ILE MI
48138-1027
US

IV. Provider business mailing address

19891 PARKE LN
GROSSE ILE MI
48138-1027
US

V. Phone/Fax

Practice location:
  • Phone: 734-671-6677
  • Fax:
Mailing address:
  • Phone: 734-671-6677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5101011021
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number5101011021
License Number StateMI

VIII. Authorized Official

Name: MRS. ALLIE GALOVICH
Title or Position: BILLER
Credential: CPC
Phone: 248-593-9780