1497487524 NPI number — CLINICAL NEUROPHYSIOLOGY CONSULTING PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497487524 NPI number — CLINICAL NEUROPHYSIOLOGY CONSULTING PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINICAL NEUROPHYSIOLOGY CONSULTING 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:
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:
1497487524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 CAMPAU CIR NW UNIT 151
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-6100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-977-0217
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 CAMPAU CIR NW UNIT 151
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-977-0217
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2022

Additional Information

Authorized Official

Authorized Official Last Name:
BURDETTE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
EDWIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
313-977-0217

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)





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