Healthcare Provider Details

I. General information

NPI: 1699227116
Provider Name (Legal Business Name): NEURO TEAM ONE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31500 TELEGRAPH RD STE 115
BINGHAM FARMS MI
48025-4302
US

IV. Provider business mailing address

6632 TELEGRAPH RD STE 204
BLOOMFIELD HILLS MI
48301-3012
US

V. Phone/Fax

Practice location:
  • Phone: 248-621-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301088851
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number4301088851
License Number StateMI

VIII. Authorized Official

Name: ANDREW RATHNASAMY XAVIER
Title or Position: MEMBER
Credential: MD
Phone: 248-621-9100