Provider Demographics
NPI:1285717249
Name:INSTITUTE OF NEUROMUSCULAR MEDICINE, PLLC
Entity type:Organization
Organization Name:INSTITUTE OF NEUROMUSCULAR MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HARDIK
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-290-2250
Mailing Address - Street 1:4300 MARSEILLES ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1479
Mailing Address - Country:US
Mailing Address - Phone:313-290-2250
Mailing Address - Fax:313-290-2257
Practice Address - Street 1:4300 MARSEILLES ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1479
Practice Address - Country:US
Practice Address - Phone:313-290-2250
Practice Address - Fax:313-290-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0855010684OtherBCBSM
MI1508852765Medicaid
MI1508852765Medicaid