Provider Demographics
NPI:1508949140
Name:MICHIGAN NEURO DIAGNOSTICS PC
Entity Type:Organization
Organization Name:MICHIGAN NEURO DIAGNOSTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-228-9065
Mailing Address - Street 1:PO BOX 380168
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-0061
Mailing Address - Country:US
Mailing Address - Phone:586-228-9065
Mailing Address - Fax:586-228-9039
Practice Address - Street 1:42621 GARFIELD
Practice Address - Street 2:STE 110
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-228-9065
Practice Address - Fax:586-228-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBN0417532084N0400X
WI49561020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1304700052OtherBCBS OF MI
F23758Medicare UPIN
MI1501147Medicare ID - Type Unspecified