Healthcare Provider Details

I. General information

NPI: 1629146527
Provider Name (Legal Business Name): ADVANCED DIAGNOSTIC IMAGING INTERVENTIONAL & VASCULAR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5462 STATE ST
SAGINAW MI
48603-3678
US

IV. Provider business mailing address

100 S JEFFERSON AVE SUITE 202
SAGINAW MI
48607-1267
US

V. Phone/Fax

Practice location:
  • Phone: 989-753-9000
  • Fax: 989-753-4024
Mailing address:
  • Phone: 989-753-9000
  • Fax: 989-753-4024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: RAMAKRISHNAYYA GADAM
Title or Position: PRESIDENT
Credential: MD
Phone: 989-753-9000