Provider Demographics
NPI:1417988031
Name:NORTHERN MICHIGAN NEUROLOGY, P.L.C.
Entity Type:Organization
Organization Name:NORTHERN MICHIGAN NEUROLOGY, P.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-0340
Mailing Address - Street 1:18688 BENDER TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE ANN
Mailing Address - State:MI
Mailing Address - Zip Code:49650-9434
Mailing Address - Country:US
Mailing Address - Phone:231-499-1037
Mailing Address - Fax:231-935-0434
Practice Address - Street 1:18688 BENDER TRL
Practice Address - Street 2:
Practice Address - City:LAKE ANN
Practice Address - State:MI
Practice Address - Zip Code:49650-9434
Practice Address - Country:US
Practice Address - Phone:231-499-1037
Practice Address - Fax:231-935-0434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBE0624792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3067916Medicaid
MI3067916Medicaid
MIC74432Medicare UPIN