Basic Information
| Provider Information | |||||||||
| NPI: | 1740383009 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEUROLOGY & NEURODIAGNOSTIC CLINIC PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 643046 | ||||||||
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| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452643046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003575728 | ||||||||
| FaxNumber: | 9372912962 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 WILSON CREEK RD | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470251095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125377011 | ||||||||
| FaxNumber: | 8125377021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 09/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | SIDDIQUI | ||||||||
| AuthorizedOfficialFirstName: | USMAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8125377011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0937400 | 05 | OH | MEDICAID | 65937062 | 05 | KY | MEDICAID | 100319400A | 05 | IN | MEDICAID | 348882200 | 01 | US DEPT OF LABOR | OTHER |