Basic Information
| Provider Information | |||||||||
| NPI: | 1366541138 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID MICHIGAN RADIOLOGY ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 S CRAPO ST STE F | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488582961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897732081 | ||||||||
| FaxNumber: | 9897733418 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 S CRAPO ST | ||||||||
| Address2: | SUITE F | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897732081 | ||||||||
| FaxNumber: | 9897733418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | BUITEWEG | ||||||||
| AuthorizedOfficialFirstName: | JOHANNES | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9897732081 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0204X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1379244 | 05 | MI | MEDICAID | 300C76006 | 01 | MI | BCBS OF MICHIGAN | OTHER |