=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548259948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NDS RADIOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2005
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28700 CABOT DR STE 500
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48377-2949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-476-6980
-----------------------------------------------------
Fax | 248-476-7462
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28700 CABOT DR STE 500
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48377-2949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-476-6980
-----------------------------------------------------
Fax | 248-476-7462
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MICHAEL KETSLAKH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-476-6980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------