Basic Information
| Provider Information | |||||||||
| NPI: | 1942263736 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIVONIA RADIOLOGY GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14555 LEVAN | ||||||||
| Address2: | STE 310 | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481545085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345911171 | ||||||||
| FaxNumber: | 7345911656 | ||||||||
| Practice Location | |||||||||
| Address1: | 36475 5 MILE | ||||||||
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| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481541971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346554800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOHTADI | ||||||||
| AuthorizedOfficialFirstName: | NADER | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7345911171 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 3516119 | 05 | MI | MEDICAID |