1508949140 NPI number — MICHIGAN NEURO DIAGNOSTICS PC

Table of content: (NPI 1508949140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508949140 NPI number — MICHIGAN NEURO DIAGNOSTICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN NEURO DIAGNOSTICS PC
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:
1508949140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 380168
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-0061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-228-9065
Provider Business Mailing Address Fax Number:
586-228-9039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42621 GARFIELD
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-228-9065
Provider Business Practice Location Address Fax Number:
586-228-9039
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
GARRETT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
586-228-9065

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  BN041753 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208600000X , with the licence number: 49561020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 1304700052 . This is a "BCBS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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