=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285912063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID MICHIGAN IMAGING SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2011
-----------------------------------------------------
Last Update Date | 03/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8273 S SAGINAW ST STE D
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439-2465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-606-0656
-----------------------------------------------------
Fax | 810-606-0662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2370 S LINDEN RD STE 300A
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48532-5429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-715-9915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JANE HICKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-715-9915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 4301067627
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------