Healthcare Provider Details

I. General information

NPI: 1912049099
Provider Name (Legal Business Name): MI NEUROSURGERY CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 GENESYS PKWY
GRAND BLANC MI
48439-8070
US

IV. Provider business mailing address

3495 S CENTER RD
BURTON MI
48519-1455
US

V. Phone/Fax

Practice location:
  • Phone: 810-606-7535
  • Fax: 810-606-7510
Mailing address:
  • Phone: 810-424-2007
  • Fax: 810-743-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601004125
License Number StateMI

VIII. Authorized Official

Name: DAWN TARTAGLIONE
Title or Position: OWNER
Credential: DO
Phone: 810-424-2007