Provider Demographics
NPI:1518003334
Name:ADVANCED NEUROSCIENCE CLINIC, PA
Entity Type:Organization
Organization Name:ADVANCED NEUROSCIENCE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANOHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:GURRU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-570-9991
Mailing Address - Street 1:PO BOX 4100
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79704
Mailing Address - Country:US
Mailing Address - Phone:432-570-9991
Mailing Address - Fax:432-570-9998
Practice Address - Street 1:3400 ANDREWS HWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-5100
Practice Address - Country:US
Practice Address - Phone:432-570-9991
Practice Address - Fax:432-570-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL29142084N0400X, 2084N0600X, 2084S0012X
TXM38332084N0400X, 2084N0600X
TXPA04008363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0018HQOtherBCBS
TX149225801Medicaid
TX0018HQOtherBCBS