Provider Demographics
NPI:1740383009
Name:NEUROLOGY & NEURODIAGNOSTIC CLINIC PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:NEUROLOGY & NEURODIAGNOSTIC CLINIC PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:USMAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-537-7011
Mailing Address - Street 1:PO BOX 643046
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-3046
Mailing Address - Country:US
Mailing Address - Phone:800-357-5728
Mailing Address - Fax:937-291-2962
Practice Address - Street 1:606 WILSON CREEK RD
Practice Address - Street 2:STE. 210
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-1095
Practice Address - Country:US
Practice Address - Phone:812-537-7011
Practice Address - Fax:812-537-7021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0937400Medicaid
KY65937062Medicaid
IN100319400AMedicaid
348882200OtherUS DEPT OF LABOR
IN190180Medicare PIN
OH9321801Medicare PIN