Provider Demographics
NPI:1104271014
Name:NEURODX LLC
Entity type:Organization
Organization Name:NEURODX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:PEGUERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-443-6957
Mailing Address - Street 1:4714 N ARMENIA AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2603
Mailing Address - Country:US
Mailing Address - Phone:813-443-6957
Mailing Address - Fax:813-443-4891
Practice Address - Street 1:4714 N ARMENIA AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2603
Practice Address - Country:US
Practice Address - Phone:813-443-6957
Practice Address - Fax:813-443-4891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE90247Medicare UPIN