=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487968475
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED NEUROLOGIC ASSOCIATES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2010
-----------------------------------------------------
Last Update Date | 12/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 PROSPECT ST SUITE 302
-----------------------------------------------------
City | SANDUSKY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44870-3362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-483-2403
-----------------------------------------------------
Fax | 419-484-1203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5433 STATE ROUTE 113
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44811-9708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-483-2403
-----------------------------------------------------
Fax | 419-484-1203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEVEN BENEDICT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 419-483-2403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------