Provider Demographics
NPI:1528513199
Name:RADIOLOGY GROUP LLC
Entity type:Organization
Organization Name:RADIOLOGY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-422-4680
Mailing Address - Street 1:42383 GARFIELD RD UNIT 380560
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7718
Mailing Address - Country:US
Mailing Address - Phone:727-422-4680
Mailing Address - Fax:313-406-7255
Practice Address - Street 1:27789 MOUND RD STE 100
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2697
Practice Address - Country:US
Practice Address - Phone:313-209-3353
Practice Address - Fax:313-406-7255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1043253602174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty