Provider Demographics
NPI:1639134414
Name:GLENDALE NEUROLOGICAL ASSOCIATES P C
Entity Type:Organization
Organization Name:GLENDALE NEUROLOGICAL ASSOCIATES P C
Other - Org Name:MICHIGAN INSTITUTE FOR NEUROLOGICAL DISORDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOUDOURIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-553-0010
Mailing Address - Street 1:28595 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2977
Mailing Address - Country:US
Mailing Address - Phone:248-553-0010
Mailing Address - Fax:248-553-0818
Practice Address - Street 1:28595 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2977
Practice Address - Country:US
Practice Address - Phone:248-553-0010
Practice Address - Fax:248-553-0818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2084N0400X
208VP0014X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty