1689879629 NPI number — MICHIGAN NEUROLOGY, P.L.L.C.

Table of content: (NPI 1689879629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689879629 NPI number — MICHIGAN NEUROLOGY, P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN NEUROLOGY, P.L.L.C.
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:
1689879629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1030 HARRINGTON ST
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
MOUNT CLEMENS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48043-2967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-493-3188
Provider Business Mailing Address Fax Number:
586-493-3191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1030 HARRINGTON ST
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
MOUNT CLEMENS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48043-2967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-493-3188
Provider Business Practice Location Address Fax Number:
586-493-3191
Provider Enumeration Date:
06/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BURNHAM
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
ANNE-MARIE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
586-493-3188

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  JH012296 , 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: 4461374 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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