=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023023686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKEPOINTE RADIOLOGY, P. C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 468 CADIEUX RD
-----------------------------------------------------
City | GROSSE POINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48230-1507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-343-1630
-----------------------------------------------------
Fax | 313-343-1631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1108 ATTN: BARB SIMMONS
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48106-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-677-7400
-----------------------------------------------------
Fax | 734-677-7407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ARUN G PATEL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 313-343-1562
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------