Provider Demographics
NPI:1568638088
Name:DEARBORN NURO CLINIC PC
Entity Type:Organization
Organization Name:DEARBORN NURO CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MAAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-724-9584
Mailing Address - Street 1:25325 FORD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1086
Mailing Address - Country:US
Mailing Address - Phone:313-724-0584
Mailing Address - Fax:
Practice Address - Street 1:25325 FORD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1086
Practice Address - Country:US
Practice Address - Phone:313-724-0584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053885204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1308248992OtherBLUE CROSS BLUE SHEILD OF MI
MI4579561Medicaid
MI4579561Medicaid
MI=========OtherTAX ID