Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 2085R0202X | Radiology | Diagnostic Radiology | 00 | MICHIGAN | No |
| 2 | 2085R0204X | Radiology | Vascular & Interventional Radiology | 00 | MICHIGAN | No |
| 3 | 2085N0904X | Radiology | Nuclear Radiology | 00 | MICHIGAN | No |
| 4 | 261QR0206X | Clinic/Center | Radiology, Mammography | | MICHIGAN | No |
| 5 | 2085U0001X | Radiology | Diagnostic Ultrasound | 00 | MICHIGAN | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 506377 | OTHER | MICHIGAN | CARE CHOICES GROUP PIN |
| 2 | RA630034 | OTHER | MICHIGAN | MCARE GROUP PIN |
| 3 | 1007775-001 | OTHER | MICHIGAN | WELLNESS PLAN GROUP PIN |
| 4 | 5006540 | OTHER | MICHIGAN | AETNA GROUP PIN |
| 5 | QMXPR0014590 | OTHER | MICHIGAN | MOLINA |
| 6 | 0P00030 | MEDICARE PIN | MICHIGAN | |
| 7 | 132484 | OTHER | MICHIGAN | GREAT LAKE HEALTH PLAN |
| 8 | 0M38520 | MEDICARE PIN | MICHIGAN | |
| 9 | OF372090 | OTHER | MICHIGAN | BLUE SHIELD GROUP PIN |
| 10 | 0N91750 | MEDICARE PIN | MICHIGAN | |
| 11 | 5101 | OTHER | MICHIGAN | CAPE HEALTH PLAN GROUP |
