Provider Demographics
NPI:1912199852
Name:DIAGNOSTIC NEUROLOGICAL ASSOCIATES
Entity Type:Organization
Organization Name:DIAGNOSTIC NEUROLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MICELI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-588-2930
Mailing Address - Street 1:PO BOX 481123
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-6123
Mailing Address - Country:US
Mailing Address - Phone:847-588-2930
Mailing Address - Fax:847-588-3341
Practice Address - Street 1:7437 N HARLEM AVE
Practice Address - Street 2:#105
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3701
Practice Address - Country:US
Practice Address - Phone:847-588-2930
Practice Address - Fax:847-588-3341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG28401Medicare UPIN