Provider Demographics
NPI:1629467204
Name:MICHIGAN NEUROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:MICHIGAN NEUROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GIANCARLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-445-9900
Mailing Address - Street 1:34025 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3737
Mailing Address - Country:US
Mailing Address - Phone:586-445-9900
Mailing Address - Fax:
Practice Address - Street 1:34025 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-3737
Practice Address - Country:US
Practice Address - Phone:586-445-9900
Practice Address - Fax:586-464-2231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105998302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization