Healthcare Provider Details

I. General information

NPI: 1043220205
Provider Name (Legal Business Name): BEAUMONT SPECIAL RADIOLOGICAL PROCEDURES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W THIRTEEN MILE RD
ROYAL OAK MI
48073
US

IV. Provider business mailing address

PO BOX 64011
DETROIT MI
48264-0001
US

V. Phone/Fax

Practice location:
  • Phone: 248-898-6064
  • Fax: 248-898-5490
Mailing address:
  • Phone: 586-412-4000
  • Fax: 586-412-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DUANE G. MEZWA
Title or Position: CHIEF OF RAD DEPT/PROGRAM DIRECTOR
Credential: MD
Phone: 248-898-6064