Provider Demographics
NPI:1285800417
Name:MID MICHIGAN DIAGNOSTIC CORP
Entity type:Organization
Organization Name:MID MICHIGAN DIAGNOSTIC CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZAKWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOUDANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-606-0656
Mailing Address - Street 1:1309 S LINDEN RD STE A
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3443
Mailing Address - Country:US
Mailing Address - Phone:810-606-0656
Mailing Address - Fax:810-606-0662
Practice Address - Street 1:1309 S LINDEN RD STE A
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3443
Practice Address - Country:US
Practice Address - Phone:810-606-0656
Practice Address - Fax:810-606-0662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084975207RS0012X
MIKH0721332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104809895Medicaid
MI105207154Medicaid
MI0P29540Medicare PIN