1467576132 NPI number — NORTHWEST NEUROLOGY PC

Table of content: (NPI 1467576132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467576132 NPI number — NORTHWEST NEUROLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST NEUROLOGY 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:
6
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:
1467576132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27200 LAHSER RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48034-2137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-208-9215
Provider Business Mailing Address Fax Number:
248-208-9217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27200 LAHSER RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48034-2137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-208-9215
Provider Business Practice Location Address Fax Number:
248-208-9217
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JENKINS
Authorized Official First Name:
TESSY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-208-9215

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  4301058568 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4639614 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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