Basic Information
| Provider Information | |||||||||
| NPI: | 1568420040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAZGARI | ||||||||
| FirstName: | REZA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 23625 COMMERCE PARK | ||||||||
| Address2: | STE 204 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555700 | ||||||||
| FaxNumber: | 2162555701 | ||||||||
| Practice Location | |||||||||
| Address1: | 32227 ARLINGTON DRIVE | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480254217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489534703 | ||||||||
| FaxNumber: | 2162555701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 01/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301074768 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4930796 | 05 | MI | MEDICAID | 700F340300 | 01 | MI | BCBS PROF GRP PIN | OTHER | 2085R020X | 01 | MI | TAXONOMY | OTHER | 2905762 | 05 | OH | MEDICAID | I08753 | 01 | MI | UPIN | OTHER | 700E021910 | 01 | MI | BCBS PROF GRP PIN | OTHER | 1620742 | 05 | LA | MEDICAID | 383162435 | 01 | MI | TAX ID COMMERCIAL INSURANCE | OTHER | RS074768 | 01 | MI | STATE LICENSE | OTHER | 700E021830 | 01 | MI | BCBS PROF GRP PIN | OTHER | 4769421 | 05 | MI | MEDICAID | 5968608 | 01 | MI | AETNA | OTHER | P00433250 | 01 | MI | GBA PALMETTO RAILROAD MEDICARE | OTHER |