Healthcare Provider Details

I. General information

NPI: 1396454856
Provider Name (Legal Business Name): WISCONSIN CENTER FOR NEUROLOGICAL DISORDERS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10750 W HOWARD AVE
GREENFIELD WI
53228-1321
US

IV. Provider business mailing address

10750 W HOWARD AVE
GREENFIELD WI
53228-1321
US

V. Phone/Fax

Practice location:
  • Phone: 414-460-3195
  • Fax:
Mailing address:
  • Phone: 414-460-3195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: NISHIT NIRMAL
Title or Position: ADMINISTRATOR
Credential:
Phone: 414-460-3195