Provider Demographics
NPI:1871886952
Name:ISOMM LLC
Entity type:Organization
Organization Name:ISOMM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
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:PO BOX 3701
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-3701
Mailing Address - Country:US
Mailing Address - Phone:989-773-2081
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:211 S CRAPO ST
Practice Address - Street 2:STE H
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2961
Practice Address - Country:US
Practice Address - Phone:734-677-7400
Practice Address - Fax:734-677-7407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C70065OtherBCBS GROUP