1114704764 NPI number — MICHIGAN MINIMALLY INVASIVE NEUROSURGICAL INSTITUTE PLLC

Table of content: (NPI 1114704764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114704764 NPI number — MICHIGAN MINIMALLY INVASIVE NEUROSURGICAL INSTITUTE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN MINIMALLY INVASIVE NEUROSURGICAL INSTITUTE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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Provider Other Middle Name:
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NPI Number Information

NPI Number:
1114704764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1070 TIMBERLAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302-2849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-383-1030
Provider Business Mailing Address Fax Number:
248-383-1031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5220 HIGHLAND RD STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48327-1973
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-383-1030
Provider Business Practice Location Address Fax Number:
248-383-1031
Provider Enumeration Date:
09/08/2023

Additional Information

Authorized Official

Authorized Official Last Name:
PEREZ-CRUET
Authorized Official First Name:
MIGUELANGELO
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-535-6952

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)





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