Basic Information
| Provider Information | |||||||||
| NPI: | 1871886952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ISOMM LLC | ||||||||
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| OtherOrganizationName: | OPEN MRI MT PLEASANT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3701 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481063701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897732081 | ||||||||
| FaxNumber: | 7346777407 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 S CRAPO ST | ||||||||
| Address2: | STE H | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488582961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346777400 | ||||||||
| FaxNumber: | 7346777407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2011 | ||||||||
| LastUpdateDate: | 03/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | BUITEWEG | ||||||||
| AuthorizedOfficialFirstName: | JOHANNES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9897732081 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0C70065 | 01 | MI | BCBS GROUP | OTHER |