MEDICARE: MICHIGAN NEUROLOGY ASSOCIATES DME

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	332B00000X	Durable Medical Equipment & Medical Supplies	5101008581	MI
2	2084N0400X	Neurology Physician	5101008571	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	540E007730	OTHER	MI	BCBSM

General Provider Information

NPI Number	:	1952556078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN NEUROLOGY ASSOCIATES DME

Provider Business Mailing Address
First Line	:	34025 HARPER AVE
Second Line	:
City	:	CLINTON TWP
State	:	MI
Zip	:	48035-3737
Country	:	US
Telephone Number	:	586-445-9900
Fax Number	:

Provider Business Practice Location Address
First Line	:	34025 HARPER AVE
Second Line	:
City	:	CLINTON TWP
State	:	MI
Zip	:	48035-3737
Country	:	US
Telephone Number	:	586-445-9900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT, MNA
Name	:	THOMAS GIANCARLO
Credential	:	DO
Telephone Number	:	586-445-9900

Provider Enumeration Date	:	11/18/2008
Last Update Date	:	08/29/2016

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