Basic Information
| Provider Information | |||||||||
| NPI: | 1811214265 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN TELERAD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13737 NOEL RD | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752401331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2147122074 | ||||||||
| FaxNumber: | 2147122487 | ||||||||
| Practice Location | |||||||||
| Address1: | 45765 TOURNAMENT DR | ||||||||
| Address2: | |||||||||
| City: | NORTHVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481688581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487674579 | ||||||||
| FaxNumber: | 2147122487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2010 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | TEMPLETON | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2147122074 | ||||||||
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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 | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.