=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114052628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MI NEUROSURGERY CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3635 GENESYS PKWY
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439-8070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-606-7535
-----------------------------------------------------
Fax | 810-606-7510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3495 S CENTER RD
-----------------------------------------------------
City | BURTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48519-1455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-424-2007
-----------------------------------------------------
Fax | 810-743-1099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAWN TARTAGLIONE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 810-424-2007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | 5101012775
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------