=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699853523
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINAL THERAPEUTICS CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22731 NEWMAN ST SUITE 102
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48124-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-792-8742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2084
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48123-2084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-792-8472
-----------------------------------------------------
Fax | 313-792-2782
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. EARL E. MCHUGH
-----------------------------------------------------
Credential | CLU, CHFC
-----------------------------------------------------
Telephone | 248-229-7878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5101006701
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------