Provider Demographics
NPI:1275043853
Name:SPORTS NEUROLOGY CLINIC
Entity Type:Organization
Organization Name:SPORTS NEUROLOGY CLINIC
Other - Org Name:THE SPORTS NEUROLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NATIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-223-4581
Mailing Address - Street 1:8273 GRAND RIVER RD STE 210
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-9346
Mailing Address - Country:US
Mailing Address - Phone:810-522-6080
Mailing Address - Fax:
Practice Address - Street 1:8273 GRAND RIVER RD STE 210
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9346
Practice Address - Country:US
Practice Address - Phone:734-223-4581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-09
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084S0010XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySports MedicineGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD.203771OtherLOUISIANA STATE BOARD OF MEDICAL EXAMINERS
AZ51983OtherARIZONA MEDICAL BOARD
MI4301073973OtherSTATE OF MICHIGAN BOARD OF MEDICINE
UT8919590-1205OtherSTATE OF UTAH BOARD OF MEDICINE
FLME131286OtherFLORIDA DEPARTMENT OF HEALTH