Basic Information
| Provider Information | |||||||||
| NPI: | 1114165842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEURALWATCH ILLINOIS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 812 AVIS DR | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481089649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342133920 | ||||||||
| FaxNumber: | 8666342766 | ||||||||
| Practice Location | |||||||||
| Address1: | 812 AVIS DR | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481089649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342133920 | ||||||||
| FaxNumber: | 8666342766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2009 | ||||||||
| LastUpdateDate: | 02/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | BALZER | ||||||||
| AuthorizedOfficialFirstName: | GENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 73473213920 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.