Provider Demographics
NPI:1548259948
Name:NDS RADIOLOGY PLLC
Entity type:Organization
Organization Name:NDS RADIOLOGY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KETSLAKH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-476-6980
Mailing Address - Street 1:28700 CABOT DR STE 500
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2949
Mailing Address - Country:US
Mailing Address - Phone:248-476-6980
Mailing Address - Fax:248-476-7462
Practice Address - Street 1:28700 CABOT DR STE 500
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2949
Practice Address - Country:US
Practice Address - Phone:248-476-6980
Practice Address - Fax:248-476-7462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F322820OtherBCBS/BCN
MI7135655OtherAETNA
195714OtherCIGNA
MI700F322820OtherBCBS/BCN
=========OtherPPOM
=========OtherPPOM
MION86680Medicare ID - Type Unspecified