Healthcare Provider Details

I. General information

NPI: 1417988031
Provider Name (Legal Business Name): NORTHERN MICHIGAN NEUROLOGY, P.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18688 BENDER TRL
LAKE ANN MI
49650-9434
US

IV. Provider business mailing address

18688 BENDER TRL
LAKE ANN MI
49650-9434
US

V. Phone/Fax

Practice location:
  • Phone: 231-499-1037
  • Fax: 231-935-0434
Mailing address:
  • Phone: 231-499-1037
  • Fax: 231-935-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberBE062479
License Number StateMI

VIII. Authorized Official

Name: DR. BRADLEY K. EVANS
Title or Position: PROVIDER
Credential: M.D.
Phone: 231-935-0340