MEDICARE: BRILLIANT GLORY NIMMER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	64290-20	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982047411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRILLIANT GLORY NIMMER M.D.

Provider Business Mailing Address
First Line	:	9000 W WISCONSIN AVE
Second Line	:	MS 958
City	:	MILWAUKEE
State	:	WI
Zip	:	53226-4874
Country	:	US
Telephone Number	:	414-266-7615
Fax Number	:	414-266-6238

Provider Business Practice Location Address
First Line	:	2561 N 29TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-3116
Country	:	US
Telephone Number	:	414-264-5338
Fax Number	:	414-264-5625

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2013
Last Update Date	:	07/14/2016

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