Provider Demographics
NPI:1386736536
Name:NEUROSURGERY GROUP, P.C.
Entity type:Organization
Organization Name:NEUROSURGERY GROUP, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:THERESA
Authorized Official - Last Name:CHISHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-412-8566
Mailing Address - Street 1:43650 GARFIELD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6332
Mailing Address - Country:US
Mailing Address - Phone:586-263-0820
Mailing Address - Fax:586-263-3819
Practice Address - Street 1:43650 GARFIELD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-6332
Practice Address - Country:US
Practice Address - Phone:586-263-0820
Practice Address - Fax:586-263-3819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI052399207T00000X
MI028777207T00000X
MI405324208100000X
MI0518332084N0400X
MI5601002721363AM0700X
MI5601003971363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1437099Medicaid
MI4815088Medicaid
MI1891095Medicaid
MI4815097Medicaid
MI1891095Medicaid
A75015Medicare UPIN
F25013Medicare UPIN
MI4815088Medicaid
F00482Medicare UPIN
0500452Medicare ID - Type Unspecified
B45700Medicare UPIN
0500776Medicare ID - Type Unspecified
N88620001Medicare ID - Type Unspecified