Provider Demographics
NPI:1235355744
Name:NORTHGATE NEUROLOGY, PLLC
Entity Type:Organization
Organization Name:NORTHGATE NEUROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-877-1212
Mailing Address - Street 1:PO BOX 28107
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37424-8107
Mailing Address - Country:US
Mailing Address - Phone:423-877-1212
Mailing Address - Fax:423-877-6793
Practice Address - Street 1:2051 HAMILL RD
Practice Address - Street 2:SUITE 301B
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4026
Practice Address - Country:US
Practice Address - Phone:423-877-1212
Practice Address - Fax:423-877-6793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 19747174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN166110100OtherDEPARTMENT OF LABOR