MEDICARE: DEARBORN NURO CLINIC PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	4301053885	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1308248992	OTHER	MI	BLUE CROSS BLUE SHEILD OF MI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568638088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEARBORN NURO CLINIC PC

Provider Business Mailing Address
First Line	:	25325 FORD RD
Second Line	:	SUITE 100
City	:	DEARBORN
State	:	MI
Zip	:	48128-1086
Country	:	US
Telephone Number	:	313-724-0584
Fax Number	:

Provider Business Practice Location Address
First Line	:	25325 FORD RD
Second Line	:	SUITE 100
City	:	DEARBORN
State	:	MI
Zip	:	48128-1086
Country	:	US
Telephone Number	:	313-724-0584
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BASSAM MAAZ
Credential	:	MD
Telephone Number	:	313-724-9584

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	05/05/2008

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