Provider Demographics
NPI:1538178934
Name:MIDWEST DIAGNOSTIC IMAGING, INC
Entity type:Organization
Organization Name:MIDWEST DIAGNOSTIC IMAGING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:SONDERGELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-681-2000
Mailing Address - Street 1:5463 ELIZABETH LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-2752
Mailing Address - Country:US
Mailing Address - Phone:248-681-2000
Mailing Address - Fax:248-681-7319
Practice Address - Street 1:5463 ELIZABETH LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-2752
Practice Address - Country:US
Practice Address - Phone:248-681-2000
Practice Address - Fax:248-681-7319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F36344Medicare ID - Type Unspecified
MI0F36344008Medicare ID - Type Unspecified
MI0F3634409Medicare ID - Type Unspecified
MI0F36344006Medicare ID - Type Unspecified