Provider Demographics
NPI:1508086471
Name:NEUROLAB
Entity Type:Organization
Organization Name:NEUROLAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PALAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:DSC, PT, ECS
Authorized Official - Phone:248-342-9907
Mailing Address - Street 1:4385 MOTORWAY DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3451
Mailing Address - Country:US
Mailing Address - Phone:249-342-9907
Mailing Address - Fax:248-681-8077
Practice Address - Street 1:47601 GRAND RIVER AVE
Practice Address - Street 2:SUITE A 222
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1233
Practice Address - Country:US
Practice Address - Phone:248-342-9907
Practice Address - Fax:248-681-8077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208100000X
MI1276 MI2251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Not Answered2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI674675Medicare UPIN
MIOM25900Medicare ID - Type Unspecified