Provider Demographics
NPI:1164570883
Name:ADVANCED NEURODIAGNOSTIC CENTER, INC
Entity Type:Organization
Organization Name:ADVANCED NEURODIAGNOSTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SIMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRTAHERI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-885-3737
Mailing Address - Street 1:2905 KINGMAN ST FL 2
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-6615
Mailing Address - Country:US
Mailing Address - Phone:504-885-3737
Mailing Address - Fax:504-885-5507
Practice Address - Street 1:2905 KINGMAN ST
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-6615
Practice Address - Country:US
Practice Address - Phone:504-885-3737
Practice Address - Fax:504-885-5507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2084N0400X, 2084P0800X, 2084S0012X, 2085R0202X
LA2010742084P2900X
LAAP06242363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA548670743DOtherBLUE CROSS
LA4391937610OtherBCBS
LA1946613Medicaid
LA435707150COtherBCBS
LA767164775AOtherBCBS
LA1946613Medicaid