Provider Demographics
NPI:1427208768
Name:SOUTHEAST MICHIGAN BRAIN AND SPINE SURGERY, PLLC
Entity Type:Organization
Organization Name:SOUTHEAST MICHIGAN BRAIN AND SPINE SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELAOUFIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-732-8336
Mailing Address - Street 1:4800 S SAGINAW ST
Mailing Address - Street 2:SUITE 1800
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2669
Mailing Address - Country:US
Mailing Address - Phone:810-732-8336
Mailing Address - Fax:810-239-4346
Practice Address - Street 1:4800 S SAGINAW ST
Practice Address - Street 2:SUITE 1800
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2669
Practice Address - Country:US
Practice Address - Phone:810-732-8336
Practice Address - Fax:810-239-4346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093301174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619991023OtherINDIVIDUAL NPI
MI4301093301OtherSTATE LICENSE