MEDICARE: BLOOMFIELD NEUROLOGY CLINIC, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	4301031094	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	130635749	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1134202732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMFIELD NEUROLOGY CLINIC, P.C.

Provider Business Mailing Address
First Line	:	43494 WOODWARD AVE
Second Line	:	SUITE 103
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-5052
Country	:	US
Telephone Number	:	248-338-8400
Fax Number	:	248-338-8151

Provider Business Practice Location Address
First Line	:	43494 WOODWARD AVE
Second Line	:	SUITE 103
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-5052
Country	:	US
Telephone Number	:	248-338-8400
Fax Number	:	248-338-8151

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LIONEL GLASS
Credential	:	M.D.
Telephone Number	:	248-338-8400

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	04/15/2009

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Directions to “BLOOMFIELD NEUROLOGY CLINIC, P.C. ” Practice Location

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