Provider Demographics
NPI:1710086160
Name:SAGINAW VALLEY NEUROSURGERY, P.L.L.C.
Entity Type:Organization
Organization Name:SAGINAW VALLEY NEUROSURGERY, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSCIUSZKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-799-8712
Mailing Address - Street 1:4677 TOWNE CENTRE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2846
Mailing Address - Country:US
Mailing Address - Phone:989-799-8712
Mailing Address - Fax:989-791-1152
Practice Address - Street 1:4677 TOWNE CENTRE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2846
Practice Address - Country:US
Practice Address - Phone:989-799-8712
Practice Address - Fax:989-791-1152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045222207T00000X
MI4301022285207T00000X
MI43010728712084N0400X
MI5601001993363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G34525Medicare ID - Type UnspecifiedGROUP ID
MI6397270001Medicare NSC