Basic Information
Provider Information | |||||||||
NPI: | 1023023686 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKEPOINTE RADIOLOGY, P. C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1108 | ||||||||
Address2: | ATTN: BARB SIMMONS | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481061108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7346777400 | ||||||||
FaxNumber: | 7346777407 | ||||||||
Practice Location | |||||||||
Address1: | 468 CADIEUX RD | ||||||||
Address2: |   | ||||||||
City: | GROSSE POINTE | ||||||||
State: | MI | ||||||||
PostalCode: | 482301507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3133431630 | ||||||||
FaxNumber: | 3133431631 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2006 | ||||||||
LastUpdateDate: | 12/17/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATEL | ||||||||
AuthorizedOfficialFirstName: | ARUN | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3133431562 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 2085R0202X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | CB6220 | 01 | MI | RR MEDICARE# | OTHER | 310H249790 | 01 | MI | BCBS GROUP# | OTHER |