Provider Demographics
NPI:1912049099
Name:MI NEUROSURGERY CLINIC PC
Entity Type:Organization
Organization Name:MI NEUROSURGERY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:TARTAGLIONE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-424-2007
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2007
Mailing Address - Fax:810-743-1099
Practice Address - Street 1:3635 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8070
Practice Address - Country:US
Practice Address - Phone:810-606-7535
Practice Address - Fax:810-606-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N90570Medicare PIN
MIN90570001Medicare PIN