1205140290 NPI number — ADVANCED NEUROLOGIC ASSOCIATES, INC

Table of content: (NPI 1205140290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205140290 NPI number — ADVANCED NEUROLOGIC ASSOCIATES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED NEUROLOGIC ASSOCIATES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205140290
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5433 STATE ROUTE 113
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44811-9708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-483-2403
Provider Business Mailing Address Fax Number:
419-484-1203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34 EXECUTIVE DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
NORWALK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44857-2480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-483-2403
Provider Business Practice Location Address Fax Number:
419-484-1203
Provider Enumeration Date:
08/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BENEDICT
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
419-483-2403

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2383620 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: CL1664 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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