Provider Demographics
NPI:1548332851
Name:NEUROSURGICAL SPECIALISTS MGMT, PLLC
Entity type:Organization
Organization Name:NEUROSURGICAL SPECIALISTS MGMT, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NICOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-779-0588
Mailing Address - Street 1:150 N VERDE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-5256
Mailing Address - Country:US
Mailing Address - Phone:928-779-0588
Mailing Address - Fax:928-779-2358
Practice Address - Street 1:150 N VERDE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-5256
Practice Address - Country:US
Practice Address - Phone:928-779-0588
Practice Address - Fax:928-779-2358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ69272Medicare PIN