Healthcare Provider Details

I. General information

NPI: 1780761486
Provider Name (Legal Business Name): BALD MOUNTAIN DIAGNOSTIC IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 S LAPEER RD STE 104
LAKE ORION MI
48360-1421
US

IV. Provider business mailing address

1375 S LAPEER RD STE 104
LAKE ORION MI
48360-1421
US

V. Phone/Fax

Practice location:
  • Phone: 248-814-7800
  • Fax: 248-814-7801
Mailing address:
  • Phone: 248-814-7800
  • Fax: 248-814-7801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN ROBERTSON
Title or Position: PRESIDENT
Credential: D.O.
Phone: 248-814-7800