Healthcare Provider Details

I. General information

NPI: 1497487524
Provider Name (Legal Business Name): CLINICAL NEUROPHYSIOLOGY CONSULTING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 CAMPAU CIR NW UNIT 151
GRAND RAPIDS MI
49503-6100
US

IV. Provider business mailing address

160 CAMPAU CIR NW UNIT 151
GRAND RAPIDS MI
49503-6100
US

V. Phone/Fax

Practice location:
  • Phone: 313-977-0217
  • Fax:
Mailing address:
  • Phone: 313-977-0217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID EDWIN BURDETTE
Title or Position: PRESIDENT
Credential: MD
Phone: 313-977-0217