Provider Demographics
NPI:1407347743
Name:NEURO EDX, LLC
Entity Type:Organization
Organization Name:NEURO EDX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRYK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-780-6242
Mailing Address - Street 1:7270 MATT HWY STE 502-125
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028
Mailing Address - Country:US
Mailing Address - Phone:678-780-6242
Mailing Address - Fax:
Practice Address - Street 1:29488 WOODWARD AVENUE
Practice Address - Street 2:SUITE 429
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:678-780-6242
Practice Address - Fax:877-711-7411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty