Provider Demographics
NPI:1942620638
Name:CENTER FOR ADOLESCENT AND CHILD NEUROLOGY
Entity Type:Organization
Organization Name:CENTER FOR ADOLESCENT AND CHILD NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUFEMI
Authorized Official - Middle Name:OLUSEUN
Authorized Official - Last Name:SOYODE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-294-0010
Mailing Address - Street 1:422 PLYMOUTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6028
Mailing Address - Country:US
Mailing Address - Phone:616-294-0010
Mailing Address - Fax:
Practice Address - Street 1:422 PLYMOUTH AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-6028
Practice Address - Country:US
Practice Address - Phone:616-294-0010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1184735698OtherNPI - INDIVIDUAL