Provider Demographics
NPI:1689879629
Name:MICHIGAN NEUROLOGY, P.L.L.C.
Entity Type:Organization
Organization Name:MICHIGAN NEUROLOGY, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANNE-MARIE
Authorized Official - Last Name:BURNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-493-3188
Mailing Address - Street 1:1030 HARRINGTON ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2967
Mailing Address - Country:US
Mailing Address - Phone:586-493-3188
Mailing Address - Fax:586-493-3191
Practice Address - Street 1:1030 HARRINGTON ST
Practice Address - Street 2:SUITE 205
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2967
Practice Address - Country:US
Practice Address - Phone:586-493-3188
Practice Address - Fax:586-493-3191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJH012296174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4461374Medicaid
MIG76123Medicare UPIN
MI4461374Medicaid