=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922389832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCE DIAGNOSTICS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2011
-----------------------------------------------------
Last Update Date | 09/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12701 TELEGRAPH RD STE 203
-----------------------------------------------------
City | TAYLOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48180-6847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-796-4042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12701 TELEGRAPH RD STE 203
-----------------------------------------------------
City | TAYLOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48180-6847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-796-4042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MISS GHAZALA KHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-693-4011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085U0001X
-----------------------------------------------------
Taxonomy Name | Diagnostic Ultrasound Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------