Basic Information
Provider Information | |||||||||
NPI: | 1760416960 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENT RADIOLOGY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WEST MICHIGAN BUSINESS SERVICES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5329 | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486030329 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6163646700 | ||||||||
FaxNumber: | 9894014245 | ||||||||
Practice Location | |||||||||
Address1: | 200 JEFFERSON AVE SE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 49503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6163646700 | ||||||||
FaxNumber: | 6163644960 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 09/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PACIOREK | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 6166855907 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 300D148470 | 01 | MI | BCBS | OTHER |