Healthcare Provider Details

I. General information

NPI: 1912169186
Provider Name (Legal Business Name): MEDICAL DIAGNOSTIC SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 01/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4479 PONTIAC LAKE RD SUITE 1D
WATERFORD MI
48328-2059
US

IV. Provider business mailing address

3701 JARVIS AVE
SKOKIE IL
60076-4019
US

V. Phone/Fax

Practice location:
  • Phone: 248-499-7618
  • Fax: 248-499-7644
Mailing address:
  • Phone: 847-626-0800
  • Fax: 847-626-0819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name: SHAMS U SIDDIQUI
Title or Position: PRESIDENT
Credential:
Phone: 847-626-0800