MEDICARE: CLEVELAND NEUROLOGIC CLINIC, PA

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	729676	NC

General Provider Information

NPI Number	:	1669428959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEVELAND NEUROLOGIC CLINIC, PA

Provider Business Mailing Address
First Line	:	1180 WYKE RD
Second Line	:	SUITE B
City	:	SHELBY
State	:	NC
Zip	:	28150-4259
Country	:	US
Telephone Number	:	704-471-9895
Fax Number	:	704-471-9200

Provider Business Practice Location Address
First Line	:	1180 WYKE RD
Second Line	:	SUITE B
City	:	SHELBY
State	:	NC
Zip	:	28150-4259
Country	:	US
Telephone Number	:	704-471-9895
Fax Number	:	704-471-9200

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. JERRY MARTIN
Credential	:
Telephone Number	:	704-471-9895

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	11/06/2008

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