Healthcare Provider Details

I. General information

NPI: 1871886952
Provider Name (Legal Business Name): ISOMM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S CRAPO ST STE H
MT PLEASANT MI
48858-2961
US

IV. Provider business mailing address

PO BOX 3701
ANN ARBOR MI
48106-3701
US

V. Phone/Fax

Practice location:
  • Phone: 734-677-7400
  • Fax: 734-677-7407
Mailing address:
  • Phone: 989-773-2081
  • Fax: 734-677-7407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHANNES BUITEWEG
Title or Position: PARTNER
Credential: MD
Phone: 989-773-2081