Healthcare Provider Details

I. General information

NPI: 1386736536
Provider Name (Legal Business Name): NEUROSURGERY GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43650 GARFIELD
CLINTON TWP MI
48038-6332
US

IV. Provider business mailing address

43650 GARFIELD
CLINTON TWP MI
48038-6332
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-0820
  • Fax: 586-263-3819
Mailing address:
  • Phone: 586-263-0820
  • Fax: 586-263-3819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number052399
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number405324
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number051833
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601002721
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601003971
License Number StateMI
# 6
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number028777
License Number StateMI

VIII. Authorized Official

Name: MS. MARIE THERESA CHISHOLM
Title or Position: PRACTICE MANAGER
Credential:
Phone: 586-412-8566