Healthcare Provider Details

I. General information

NPI: 1609856392
Provider Name (Legal Business Name): NORTHERN NEUROSURGERY GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 W COLLEGE AVE
MARQUETTE MI
49855-2705
US

IV. Provider business mailing address

580 W COLLEGE AVE
MARQUETTE MI
49855-2705
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-4575
  • Fax:
Mailing address:
  • Phone: 906-225-4575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number4301057445
License Number StateMI

VIII. Authorized Official

Name: RICHARD A ROVIN
Title or Position: PARTNER
Credential: MD
Phone: 906-225-4575