Basic Information
| Provider Information | |||||||||
| NPI: | 1043220205 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEAUMONT SPECIAL RADIOLOGICAL PROCEDURES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64011 | ||||||||
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| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482640001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864124000 | ||||||||
| FaxNumber: | 5864124102 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 W THIRTEEN MILE RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488986064 | ||||||||
| FaxNumber: | 2488985490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | MEZWA | ||||||||
| AuthorizedOfficialFirstName: | DUANE | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OF RAD DEPT/PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2488986064 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.