Provider Demographics
NPI:1164619763
Name:WEST BRANCH NERUOLOGY
Entity Type:Organization
Organization Name:WEST BRANCH NERUOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-345-4343
Mailing Address - Street 1:335 E HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-1127
Mailing Address - Country:US
Mailing Address - Phone:989-345-4343
Mailing Address - Fax:989-345-4344
Practice Address - Street 1:335 E HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-1127
Practice Address - Country:US
Practice Address - Phone:989-345-4343
Practice Address - Fax:989-345-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDP0096462084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1012243OtherHEALTH ADVANTAGE
P00203101OtherMEDICARE RAILROAD
MI1356510065OtherBLUE CROSS BLUE SHIELD
MIOP03260001OtherMEDICARE PLUS BLUE
MIE87926Medicare UPIN