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General NPI Number Information
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NPI Number | 1760404891
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Entity Type | Organization
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Legal Business Name | GRAND TRAVERSE RADIOLOGISTS PC
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Dates
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Enumeration Date | 07/25/2006
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Last Update Date | 04/29/2020
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Provider Practice Location Address
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Address Line | 1105 SIXTH ST
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-2345
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Country | US
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Telephone | 231-935-0497
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 30516 DEPT. 9516
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City | LANSING
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State | MI
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Zip | 48909-8016
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Country | US
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Telephone | 800-475-6112
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Fax | 423-826-1286
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHELLE M LUNG
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Credential | MD
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Telephone | 231-935-0497
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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