Basic Information
| Provider Information | |||||||||
| NPI: | 1467576132 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST NEUROLOGY PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHWEST NEUROLOGY AND NEURODIAGNOSTIC CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27200 LAHSER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482089215 | ||||||||
| FaxNumber: | 2482089217 | ||||||||
| Practice Location | |||||||||
| Address1: | 27200 LAHSER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482089215 | ||||||||
| FaxNumber: | 2482089217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 10/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | JENKINS | ||||||||
| AuthorizedOfficialFirstName: | TESSY | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2482089215 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 4301058568 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 4639614 | 05 | MI | MEDICAID |