MEDICARE: CENTENNIAL NEUROLOGY, PLLC

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		CO

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

General Provider Information

NPI Number	:	1205940871
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTENNIAL NEUROLOGY, PLLC

Provider Business Mailing Address
First Line	:	7251 W 20TH ST UNIT C
Second Line	:
City	:	GREELEY
State	:	CO
Zip	:	80634-4626
Country	:	US
Telephone Number	:	970-356-3876
Fax Number	:	970-353-8810

Provider Business Practice Location Address
First Line	:	7251 W 20TH ST UNIT C
Second Line	:
City	:	GREELEY
State	:	CO
Zip	:	80634-4626
Country	:	US
Telephone Number	:	970-356-3876
Fax Number	:	970-353-8810

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID L EWING
Credential	:	MD
Telephone Number	:	970-356-3876

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	04/13/2011

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