Provider Demographics
NPI:1033548581
Name:MICHIGAN NEUROSCIENCE CLINIC PLLC
Entity Type:Organization
Organization Name:MICHIGAN NEUROSCIENCE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-231-4460
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-0086
Mailing Address - Country:US
Mailing Address - Phone:734-374-1112
Mailing Address - Fax:734-374-1119
Practice Address - Street 1:11780 TELEGRAPH RD STE 100
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6862
Practice Address - Country:US
Practice Address - Phone:734-374-1112
Practice Address - Fax:734-374-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010926822084N0400X
MI43010932122084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI7264OtherMEDICARE PTAN LOCALITY 99
MIMI7263Medicare PIN