1528038866 NPI number — SPINE NEUROSURGERY INST OF NE WI S.C.

Table of content: (NPI 1528038866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528038866 NPI number — SPINE NEUROSURGERY INST OF NE WI S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE NEUROSURGERY INST OF NE WI S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528038866
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3409 NICOLET DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54311-7203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-846-8057
Provider Business Mailing Address Fax Number:
920-846-4588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
835 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
OCONTO FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54154-1282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-846-8057
Provider Business Practice Location Address Fax Number:
920-846-4588
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PEREIRA
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
920-846-8057

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  39920-20 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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