Provider Demographics
NPI:1053362228
Name:WOODLAND IMAGING CENTER LLC
Entity type:Organization
Organization Name:WOODLAND IMAGING CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FUGENSCHUH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-712-8350
Mailing Address - Street 1:7575 GRAND RIVER AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-9309
Mailing Address - Country:US
Mailing Address - Phone:734-712-8350
Mailing Address - Fax:
Practice Address - Street 1:7575 GRAND RIVER AVE
Practice Address - Street 2:STE 103
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9309
Practice Address - Country:US
Practice Address - Phone:734-712-8350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00350162OtherRAILROAD MEDICARE
MI0P47820Medicare PIN
MI0P37950Medicare PIN