Provider Demographics
NPI:1366541138
Name:MID MICHIGAN RADIOLOGY ASSOCIATES, P.C.
Entity type:Organization
Organization Name:MID MICHIGAN RADIOLOGY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHANNES
Authorized Official - Middle Name:
Authorized Official - Last Name:BUITEWEG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-773-2081
Mailing Address - Street 1:211 S CRAPO ST STE F
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2961
Mailing Address - Country:US
Mailing Address - Phone:989-773-2081
Mailing Address - Fax:989-773-3418
Practice Address - Street 1:211 S CRAPO ST
Practice Address - Street 2:SUITE F
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-773-2081
Practice Address - Fax:989-773-3418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1379244Medicaid
MI300C76006OtherBCBS OF MICHIGAN
MI1379244Medicaid