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General NPI Number Information
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NPI Number | 1528038866
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Entity Type | Organization
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Legal Business Name | SPINE NEUROSURGERY INST OF NE WI S.C.
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Dates
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Enumeration Date | 01/26/2006
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Last Update Date | 10/20/2008
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Provider Practice Location Address
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Address Line | 835 S MAIN ST SUITE 1
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City | OCONTO FALLS
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State | WI
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Zip | 54154-1282
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Country | US
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Telephone | 920-846-8057
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Fax | 920-846-4588
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Provider Business Mailing Address
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Address Line | 3409 NICOLET DR
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City | GREEN BAY
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State | WI
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Zip | 54311-7203
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Country | US
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Telephone | 920-846-8057
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Fax | 920-846-4588
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRYAN M PEREIRA
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Credential | M.D.
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Telephone | 920-846-8057
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number | 39920-20
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License Number State | WI
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