Basic Information
Provider Information | |||||||||
NPI: | 1578218095 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEUROLOGIC CONSULTANTS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 325 CLYDE MORRIS BLVD STE 390 | ||||||||
Address2: |   | ||||||||
City: | ORMOND BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 321748179 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3866766335 | ||||||||
FaxNumber: | 3862567629 | ||||||||
Practice Location | |||||||||
Address1: | 325 CLYDE MORRIS BLVD STE 390 | ||||||||
Address2: |   | ||||||||
City: | ORMOND BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 321748179 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3866766335 | ||||||||
FaxNumber: | 3862567629 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2022 | ||||||||
LastUpdateDate: | 02/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GAREWAL | ||||||||
AuthorizedOfficialFirstName: | MANDEEP | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3866766335 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 02/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084S0012X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 2084N0400X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.