MEDICARE: TRI-COUNTY NEUROLOGICAL ASSOCIATES

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	363AM0700X	Medical Physician Assistant	5601005798	MI

General Provider Information

NPI Number	:	1316349236
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-COUNTY NEUROLOGICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	39581 GARFIELD RD
Second Line	:
City	:	CLINTON TWP
State	:	MI
Zip	:	48038-4300
Country	:	US
Telephone Number	:	586-286-2770
Fax Number	:	586-286-9080

Provider Business Practice Location Address
First Line	:	39581 GARFIELD RD
Second Line	:
City	:	CLINTON TWP
State	:	MI
Zip	:	48038-4300
Country	:	US
Telephone Number	:	586-286-2770
Fax Number	:	586-286-9080

Authorized Official
Title or Position	:	PHYSICIAN ASSISTANT
Name	:	MRS. NICHOLE WORTHING
Credential	:	PA-C
Telephone Number	:	586-286-2770

Provider Enumeration Date	:	09/23/2014
Last Update Date	:	09/23/2014

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