Healthcare Provider Details

I. General information

NPI: 1336733534
Provider Name (Legal Business Name): MIDWEST SPINE CENTER SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2021
Last Update Date: 02/27/2021
Certification Date: 02/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W RIVER WOODS PKWY STE 240
GLENDALE WI
53212-1010
US

IV. Provider business mailing address

611 E LAKE HILL CT
MILWAUKEE WI
53217-4351
US

V. Phone/Fax

Practice location:
  • Phone: 414-807-6128
  • Fax:
Mailing address:
  • Phone: 414-807-6128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES E STOLL JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 414-807-6128