Basic Information
| Provider Information | |||||||||
| NPI: | 1275043853 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTS NEUROLOGY CLINIC | ||||||||
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| OtherOrganizationName: | THE SPORTS NEUROLOGY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8273 GRAND RIVER RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481149346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8105226080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8273 GRAND RIVER RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481149346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342234581 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2017 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | KUTCHER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | NATIONAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7342234581 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0402X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084S0010X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD.203771 | 01 | LA | LOUISIANA STATE BOARD OF MEDICAL EXAMINERS | OTHER | 51983 | 01 | AZ | ARIZONA MEDICAL BOARD | OTHER | 4301073973 | 01 | MI | STATE OF MICHIGAN BOARD OF MEDICINE | OTHER | 8919590-1205 | 01 | UT | STATE OF UTAH BOARD OF MEDICINE | OTHER | ME131286 | 01 | FL | FLORIDA DEPARTMENT OF HEALTH | OTHER |