Provider Demographics
NPI:1932588738
Name:SOUTHWEST MICHIGAN RADIOLOGY, PLLC
Entity type:Organization
Organization Name:SOUTHWEST MICHIGAN RADIOLOGY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-548-5687
Mailing Address - Street 1:3700 RIVERTOWN PKWY SW
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3085
Mailing Address - Country:US
Mailing Address - Phone:616-548-5687
Mailing Address - Fax:616-931-5686
Practice Address - Street 1:3700 RIVERTOWN PKWY SW
Practice Address - Street 2:SUITE 1002
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3085
Practice Address - Country:US
Practice Address - Phone:616-548-5687
Practice Address - Fax:616-931-5686
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST MICHIGAN RADIOLOGY, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-26
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2085R0202X, 261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty