Provider Demographics
NPI:1043513609
Name:ADVANCED NEUROLOGY SPECIALIST, LLC
Entity type:Organization
Organization Name:ADVANCED NEUROLOGY SPECIALIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSITA
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHIVDAT-NANHOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-225-2297
Mailing Address - Street 1:116 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-4204
Mailing Address - Country:US
Mailing Address - Phone:478-225-2297
Mailing Address - Fax:478-225-2477
Practice Address - Street 1:116 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-4204
Practice Address - Country:US
Practice Address - Phone:478-225-2297
Practice Address - Fax:478-225-2477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0620812084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G703924Medicare PIN