Provider Demographics
NPI:1699227116
Name:NEURO TEAM ONE PLLC
Entity Type:Organization
Organization Name:NEURO TEAM ONE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:RATHNASAMY
Authorized Official - Last Name:XAVIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-621-9100
Mailing Address - Street 1:6632 TELEGRAPH RD STE 204
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31500 TELEGRAPH RD STE 115
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4302
Practice Address - Country:US
Practice Address - Phone:248-621-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010888512084N0400X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4950019Medicaid
MI0P30630459Medicare PIN