Provider Demographics
NPI:1013594290
Name:WAYNE NEUROSCIENCE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:WAYNE NEUROSCIENCE MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAHEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-578-3643
Mailing Address - Street 1:34815 W MICHIGAN AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1992
Mailing Address - Country:US
Mailing Address - Phone:734-578-3643
Mailing Address - Fax:
Practice Address - Street 1:34815 W MICHIGAN AVE STE 4
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1992
Practice Address - Country:US
Practice Address - Phone:734-578-3643
Practice Address - Fax:734-725-3184
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNE NEUROSCIENCE MANAGEMENT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI130H229360OtherBLUE CROSS BLUE SHEILD