Healthcare Provider Details

I. General information

NPI: 1073243861
Provider Name (Legal Business Name): BRIAN MIKOLAJCZYK MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 KEPLER DR
GREEN BAY WI
54311-8306
US

IV. Provider business mailing address

1110 KEPLER DR
GREEN BAY WI
54311-8306
US

V. Phone/Fax

Practice location:
  • Phone: 920-304-9695
  • Fax: 512-628-3314
Mailing address:
  • Phone: 920-304-9695
  • Fax: 512-628-3314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberRL18677
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number84597-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: