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General NPI Number Information
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NPI Number | 1275043853
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Entity Type | Organization
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Legal Business Name | SPORTS NEUROLOGY CLINIC
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Dates
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Enumeration Date | 10/09/2017
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Last Update Date | 12/05/2017
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Provider Practice Location Address
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Address Line | 8273 GRAND RIVER RD STE 210
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City | BRIGHTON
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State | MI
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Zip | 48114-9346
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Country | US
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Telephone | 734-223-4581
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Fax |
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Provider Business Mailing Address
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Address Line | 8273 GRAND RIVER RD STE 210
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City | BRIGHTON
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State | MI
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Zip | 48114-9346
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Country | US
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Telephone | 810-522-6080
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Fax |
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Authorized Official
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Title or Position | NATIONAL DIRECTOR
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Name | JEFFREY KUTCHER
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Credential | M.D.
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Telephone | 734-223-4581
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084N0402X
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Taxonomy Name | Neurology with Special Qualifications in Child Neurology Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084S0010X
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Taxonomy Name | Sports Medicine (Psychiatry & Neurology) Physician
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License Number |
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License Number State |
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