Healthcare Provider Details

I. General information

NPI: 1437435955
Provider Name (Legal Business Name): PHYSICIAN HEALTHCARE NETWORK-NEUROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 PINE GROVE AVENUE SUITE 1B
PORT HURON MI
48060-3500
US

IV. Provider business mailing address

3050 COMMERCE DR SUITE B
FORT GRATIOT MI
48059-3819
US

V. Phone/Fax

Practice location:
  • Phone: 810-982-9414
  • Fax: 810-985-6221
Mailing address:
  • Phone: 810-385-4441
  • Fax: 810-385-1540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DENISE KLIEMAN
Title or Position: MANAGER OF FINANCIAL SERVICES
Credential:
Phone: 810-385-8082