1215104724 NPI number — FLINT NEUROSCIENCE CENTER, PLLC

Table of content: (NPI 1215104724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215104724 NPI number — FLINT NEUROSCIENCE CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLINT NEUROSCIENCE CENTER, PLLC
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:
GREAT LAKES SPINE CENTER
Provider Other Organization Name Type Code:
3
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:
1215104724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT. CH 17809
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALATINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60055-7809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-733-7560
Provider Business Mailing Address Fax Number:
810-733-2890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
G3239 BEECHER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48532-3616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-733-7560
Provider Business Practice Location Address Fax Number:
810-733-2890
Provider Enumeration Date:
05/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ-NEGRETE
Authorized Official First Name:
HUGO
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
810-733-7560

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 700B511200 . This is a "BCBS OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: C14627 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".




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