Provider Demographics
NPI:1336130863
Name:MICHIGAN SPINE AND BRAIN SURGEONS, PLLC
Entity Type:Organization
Organization Name:MICHIGAN SPINE AND BRAIN SURGEONS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TECK
Authorized Official - Middle Name:MUN
Authorized Official - Last Name:SOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-569-7745
Mailing Address - Street 1:22250 PROVIDENCE DR
Mailing Address - Street 2:SUITE 601
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4825
Mailing Address - Country:US
Mailing Address - Phone:248-569-7745
Mailing Address - Fax:248-569-4539
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:SUITE 601
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-569-7745
Practice Address - Fax:248-569-4539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F32853OtherBLUE CROSS
MI0P20560Medicare PIN