Healthcare Provider Details

I. General information

NPI: 1053321620
Provider Name (Legal Business Name): NEUROSPINE CENTER OF WISCONSIN, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/23/2024
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 MICHAELS DR
APPLETON WI
54913-8446
US

IV. Provider business mailing address

5320 W MICHAELS DR
APPLETON WI
54913-8446
US

V. Phone/Fax

Practice location:
  • Phone: 920-882-8200
  • Fax: 920-882-8210
Mailing address:
  • Phone: 920-882-8200
  • Fax: 920-882-8210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGELA PERRONNE
Title or Position: ADMINISTRATOR
Credential:
Phone: 920-882-8200