Basic Information
| Provider Information | |||||||||
| NPI: | 1194778373 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED NEUROSURGERY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3533 SOUTHERN BLVD | ||||||||
| Address2: | STE 3000 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372998242 | ||||||||
| FaxNumber: | 9372298245 | ||||||||
| Practice Location | |||||||||
| Address1: | 3533 SOUTHERN BLVD | ||||||||
| Address2: | STE 3000 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372998242 | ||||||||
| FaxNumber: | 9372298245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | TAHA | ||||||||
| AuthorizedOfficialFirstName: | JAMAL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9372298242 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2914841 | 05 | OH | MEDICAID |