=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861030074
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | T-12 IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2019
-----------------------------------------------------
Last Update Date | 04/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29201 TELEGRAPH RD STE L-01
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-595-8404
-----------------------------------------------------
Fax | 248-996-8469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29201 TELEGRAPH RD STE L-01
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-595-8404
-----------------------------------------------------
Fax | 248-281-5155
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. GREGORY ERNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-595-8404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------