Provider Demographics
NPI:1891529111
Name:GREAT LAKES RADIOLOGY SERVICES
Entity type:Organization
Organization Name:GREAT LAKES RADIOLOGY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-673-3764
Mailing Address - Street 1:729 W ANN ARBOR TRL STE 2
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6225
Mailing Address - Country:US
Mailing Address - Phone:734-673-3764
Mailing Address - Fax:
Practice Address - Street 1:729 W ANN ARBOR TRL STE 2
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6225
Practice Address - Country:US
Practice Address - Phone:734-673-3764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-28
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty