Basic Information
| Provider Information | |||||||||
| NPI: | 1154704948 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES RADIOLOGY PLLC | ||||||||
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| Address1: | 4601 DOW RIDGE RD | ||||||||
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| City: | ORCHARD LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483242326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488840003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 461 WEST HURON | ||||||||
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| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488577200 | ||||||||
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| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | RUDRARAJU | ||||||||
| AuthorizedOfficialFirstName: | VENICAT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2488840003 | ||||||||
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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 | 2471C3402X | 4301067927 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography |
No ID Information.