Healthcare Provider Details

I. General information

NPI: 1225652993
Provider Name (Legal Business Name): NORTHLAND RADIOLOGY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20905 GREENFIELD ROAD SUITE 406
SOUTHFIELD MI
48075-5344
US

IV. Provider business mailing address

26222 TELEGRAPH ROAD
SOUTHFIELD MI
48033-5318
US

V. Phone/Fax

Practice location:
  • Phone: 248-513-8229
  • Fax: 248-479-1998
Mailing address:
  • Phone: 248-827-7200
  • Fax: 248-827-2641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RAMEGOWDA RAJAGOPAL
Title or Position: OWNER
Credential: MD
Phone: 248-827-7200