Provider Demographics
NPI:1083031496
Name:NEURO SOURCE DIAGNOSTICS, INC
Entity Type:Organization
Organization Name:NEURO SOURCE DIAGNOSTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSSIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-460-7475
Mailing Address - Street 1:9276 JAMISON AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4281
Mailing Address - Country:US
Mailing Address - Phone:215-460-7475
Mailing Address - Fax:215-677-2073
Practice Address - Street 1:9276 JAMISON AVE
Practice Address - Street 2:UNIT A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4281
Practice Address - Country:US
Practice Address - Phone:215-460-7475
Practice Address - Fax:215-677-2073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center