Healthcare Provider Details

I. General information

NPI: 1528038866
Provider Name (Legal Business Name): SPINE NEUROSURGERY INST OF NE WI S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 S MAIN ST SUITE 1
OCONTO FALLS WI
54154-1282
US

IV. Provider business mailing address

3409 NICOLET DR
GREEN BAY WI
54311-7203
US

V. Phone/Fax

Practice location:
  • Phone: 920-846-8057
  • Fax: 920-846-4588
Mailing address:
  • Phone: 920-846-8057
  • Fax: 920-846-4588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number39920-20
License Number StateWI

VIII. Authorized Official

Name: DR. BRYAN M PEREIRA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 920-846-8057