=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629119649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTLAND DIAGNOSTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25710 KELLY RD
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48066-4959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-779-4610
-----------------------------------------------------
Fax | 586-779-0003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25710 KELLY RD
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48066-4959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-779-4610
-----------------------------------------------------
Fax | 586-779-0003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MEHDI MAHMOODZADEGAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 586-779-4610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | 4301032665
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------