MEDICARE: LIVONIA RADIOLOGY GROUP PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942263736
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVONIA RADIOLOGY GROUP PC

Provider Business Mailing Address
First Line	:	14555 LEVAN
Second Line	:	STE 310
City	:	LIVONIA
State	:	MI
Zip	:	48154-5085
Country	:	US
Telephone Number	:	734-591-1171
Fax Number	:	734-591-1656

Provider Business Practice Location Address
First Line	:	36475 5 MILE
Second Line	:
City	:	LIVONIA
State	:	MI
Zip	:	48154-1971
Country	:	US
Telephone Number	:	734-655-4800
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. NADER R MOHTADI
Credential	:	MD
Telephone Number	:	734-591-1171

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	08/22/2020

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