Basic Information
| Provider Information | |||||||||
| NPI: | 1689733503 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATED RADIOLOGISTS OF CLARKSTON PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6770 DIXIE HWY STE 200 | ||||||||
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| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483462089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486252621 | ||||||||
| FaxNumber: | 2489225973 | ||||||||
| Practice Location | |||||||||
| Address1: | 7210 ORTONVILLE RD. STE 211 | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486252621 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | O'NEILL | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2486252621 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301045208 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 5187744 | 05 | MI | MEDICAID | 4996896 | 05 | MI | MEDICAID |