Provider Demographics
NPI:1336184571
Name:MICHIGAN NEUROSURGICAL INSTITUTE, P.C
Entity Type:Organization
Organization Name:MICHIGAN NEUROSURGICAL INSTITUTE, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AVERY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:810-606-7200
Mailing Address - Street 1:9400 S SAGINAW RD STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-9666
Mailing Address - Country:US
Mailing Address - Phone:810-606-7200
Mailing Address - Fax:810-606-7115
Practice Address - Street 1:9400 S SAGINAW RD STE A
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-9666
Practice Address - Country:US
Practice Address - Phone:810-606-7200
Practice Address - Fax:810-606-7115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAJ076974207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty