=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760490148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED NEUROLOGY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 676 ROUTES 202 206 N BLDG 2, SUITE 1NE
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-218-1180
-----------------------------------------------------
Fax | 908-218-1718
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1075
-----------------------------------------------------
City | SOMERVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08876-1075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-218-1180
-----------------------------------------------------
Fax | 908-218-1718
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | SRINIVASA POTLURI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 908-218-1180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MA07137500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------