Basic Information
| Provider Information | |||||||||
| NPI: | 1437435955 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN HEALTHCARE NETWORK-NEUROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 COMMERCE DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480593819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103854441 | ||||||||
| FaxNumber: | 8103851540 | ||||||||
| Practice Location | |||||||||
| Address1: | 1231 PINE GROVE AVENUE | ||||||||
| Address2: | SUITE 1B | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109829414 | ||||||||
| FaxNumber: | 8109856221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2011 | ||||||||
| LastUpdateDate: | 10/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | KLIEMAN | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER OF FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8103858082 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHYSICIAN HEALTHCARE NETWORK, PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.