Basic Information
| Provider Information | |||||||||
| NPI: | 1811258536 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COVENANT MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | MEDEXPRESS IMAGING AND DIAGNOSTICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1447 N HARRISON ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486024727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895834011 | ||||||||
| FaxNumber: | 9895832811 | ||||||||
| Practice Location | |||||||||
| Address1: | 5570 STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486033583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895830100 | ||||||||
| FaxNumber: | 9895830108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 05/30/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALBROUGH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PATIENT ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 9895836100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COVENANT MEDICAL CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.