MEDICARE: INTENSIVE NEUROMONITORING LLC

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	69752	GA

General Provider Information

NPI Number	:	1457722209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTENSIVE NEUROMONITORING LLC

Provider Business Mailing Address
First Line	:	2152 SPRING CREEK RD
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-2608
Country	:	US
Telephone Number	:	404-831-8168
Fax Number	:

Provider Business Practice Location Address
First Line	:	2152 SPRING CREEK RD
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-2608
Country	:	US
Telephone Number	:	404-831-8168
Fax Number	:

Authorized Official
Title or Position	:	OWNER - MANAGING OFFICER
Name	:	ERIC ROBERT ANDERSON
Credential	:	MD, PHD
Telephone Number	:	404-831-8168

Provider Enumeration Date	:	10/19/2015
Last Update Date	:	06/29/2016

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