Provider Demographics
NPI:1619262235
Name:WAYNE STATE UNIVERSITY/DMC
Entity Type:Organization
Organization Name:WAYNE STATE UNIVERSITY/DMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPHYSIOLOGY FELLOW
Authorized Official - Prefix:DR
Authorized Official - First Name:TEMENUZHKA
Authorized Official - Middle Name:GEORGIEVA
Authorized Official - Last Name:MIHAYLOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:313-319-4168
Mailing Address - Street 1:8316 VIRGIL ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-1520
Mailing Address - Country:US
Mailing Address - Phone:313-319-4168
Mailing Address - Fax:
Practice Address - Street 1:8316 VIRGIL ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1520
Practice Address - Country:US
Practice Address - Phone:313-319-4168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010880762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty