Provider Demographics
NPI:1154969004
Name:JAGANNATHAN NEUROSURGICAL INSTITUTE PLLC
Entity type:Organization
Organization Name:JAGANNATHAN NEUROSURGICAL INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAYANT
Authorized Official - Middle Name:
Authorized Official - Last Name:JAGANNATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-792-6527
Mailing Address - Street 1:DEPT 771749 PO BOX 77000
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2000
Mailing Address - Country:US
Mailing Address - Phone:248-792-6527
Mailing Address - Fax:248-792-9106
Practice Address - Street 1:4 COLUMBUS AVE STE 260
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6476
Practice Address - Country:US
Practice Address - Phone:989-308-1840
Practice Address - Fax:989-391-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-11
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1356680912Medicaid