Provider Demographics
NPI:1639744998
Name:WESTSIDE NEUROLOGY AND CONCUSSION CLINIC LLC
Entity Type:Organization
Organization Name:WESTSIDE NEUROLOGY AND CONCUSSION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:QUAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:706-288-8280
Mailing Address - Street 1:5398 THOMASTON RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-8110
Mailing Address - Country:US
Mailing Address - Phone:706-288-8280
Mailing Address - Fax:
Practice Address - Street 1:5398 THOMASTON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-8110
Practice Address - Country:US
Practice Address - Phone:706-288-8280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty