Provider Demographics
NPI:1457530057
Name:ANI NEUROLOGY PLLC
Entity Type:Organization
Organization Name:ANI NEUROLOGY PLLC
Other - Org Name:ALZHEIMER'S MEMORY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:BOLOURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-364-4000
Mailing Address - Street 1:7809 SARDIS RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-2757
Mailing Address - Country:US
Mailing Address - Phone:704-364-4000
Mailing Address - Fax:704-364-4005
Practice Address - Street 1:7809 SARDIS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-2757
Practice Address - Country:US
Practice Address - Phone:704-364-4000
Practice Address - Fax:704-364-4005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400301171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2052362Medicare UPIN
NC5903548Medicaid