Provider Demographics
NPI:1679803720
Name:ADVANCED MEDICAL DIAGNOSTICS, PLLC
Entity type:Organization
Organization Name:ADVANCED MEDICAL DIAGNOSTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-921-5533
Mailing Address - Street 1:1315 PORTERS LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0943
Mailing Address - Country:US
Mailing Address - Phone:248-515-7400
Mailing Address - Fax:248-548-3068
Practice Address - Street 1:1220 E 9 MILE RD
Practice Address - Street 2:A
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1972
Practice Address - Country:US
Practice Address - Phone:888-258-6825
Practice Address - Fax:248-544-4681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2841Medicare PIN