Provider Demographics
NPI:1952556078
Name:MICHIGAN NEUROLOGY ASSOCIATES DME
Entity Type:Organization
Organization Name:MICHIGAN NEUROLOGY ASSOCIATES DME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, MNA
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GIANCARLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-445-9900
Mailing Address - Street 1:34025 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3737
Mailing Address - Country:US
Mailing Address - Phone:586-445-9900
Mailing Address - Fax:
Practice Address - Street 1:34025 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-3737
Practice Address - Country:US
Practice Address - Phone:586-445-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHIGAN NEUROLOGY ASSOCIATES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-18
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010085712084N0400X
MI5101008581332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540E007730OtherBCBSM
MI3897680001Medicare PIN