Provider Demographics
NPI:1962704585
Name:NOVI NEUROLOGY PC
Entity type:Organization
Organization Name:NOVI NEUROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-347-8293
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48303-1038
Mailing Address - Country:US
Mailing Address - Phone:248-347-8293
Mailing Address - Fax:248-305-6847
Practice Address - Street 1:44000 W 12 MILE RD
Practice Address - Street 2:STE 213
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2644
Practice Address - Country:US
Practice Address - Phone:248-347-8293
Practice Address - Fax:248-305-6847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010601702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4477679Medicaid
MI0N65030Medicare PIN