Healthcare Provider Details

I. General information

NPI: 1164570883
Provider Name (Legal Business Name): ADVANCED NEURODIAGNOSTIC CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 KINGMAN ST
METAIRIE LA
70006-6615
US

IV. Provider business mailing address

2905 KINGMAN ST FL 2
METAIRIE LA
70006-6615
US

V. Phone/Fax

Practice location:
  • Phone: 504-885-3737
  • Fax: 504-885-5507
Mailing address:
  • Phone: 504-885-3737
  • Fax: 504-885-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP06242
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number201074
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: SIMIN MIRTAHERI
Title or Position: PRESIDENT
Credential:
Phone: 504-885-3737