Provider Demographics
NPI:1215361738
Name:MICHIGAN BRAIN AND SPINE
Entity type:Organization
Organization Name:MICHIGAN BRAIN AND SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRICK
Authorized Official - Middle Name:S
Authorized Official - Last Name:JUNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-996-7322
Mailing Address - Street 1:8179 HALCYON CT
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1821
Mailing Address - Country:US
Mailing Address - Phone:313-996-7322
Mailing Address - Fax:313-982-5605
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-982-5290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067029207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty