Healthcare Provider Details

I. General information

NPI: 1336175660
Provider Name (Legal Business Name): MCNICHOLS X-RAY CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 TONNACOUR PL
GROSSE POINTE FARMS MI
48236-3033
US

IV. Provider business mailing address

255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 810-489-7104
  • Fax:
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN D'ALESSANDR
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 810-489-7104