Provider Demographics
NPI:1770794737
Name:SOUTHFIELD NEUROLOGICAL ASSOC PC
Entity type:Organization
Organization Name:SOUTHFIELD NEUROLOGICAL ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:KOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-559-3150
Mailing Address - Street 1:22250 PROVIDENCE DR
Mailing Address - Street 2:SUITE 402
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4825
Mailing Address - Country:US
Mailing Address - Phone:248-559-3150
Mailing Address - Fax:248-559-8218
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:SUITE 402
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-559-3150
Practice Address - Fax:248-559-8218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBK027608174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1059871Medicaid
MI1437195013Medicare ID - Type Unspecified
MI1059871Medicaid