Provider Demographics
NPI:1669428959
Name:CLEVELAND NEUROLOGIC CLINIC, PA
Entity type:Organization
Organization Name:CLEVELAND NEUROLOGIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-471-9895
Mailing Address - Street 1:1180 WYKE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-4259
Mailing Address - Country:US
Mailing Address - Phone:704-471-9895
Mailing Address - Fax:704-471-9200
Practice Address - Street 1:1180 WYKE RD
Practice Address - Street 2:SUITE B
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4259
Practice Address - Country:US
Practice Address - Phone:704-471-9895
Practice Address - Fax:704-471-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7296762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2339791Medicare ID - Type UnspecifiedGROUP MEDICARE #