Provider Demographics
NPI:1265685093
Name:WEST SIDE NEUROLOGY SC
Entity Type:Organization
Organization Name:WEST SIDE NEUROLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:DORNBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-328-3800
Mailing Address - Street 1:2448 S 102ND ST
Mailing Address - Street 2:STE 125
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2466
Mailing Address - Country:US
Mailing Address - Phone:414-328-3800
Mailing Address - Fax:414-328-3818
Practice Address - Street 1:2448 S 102ND ST
Practice Address - Street 2:STE 125
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2466
Practice Address - Country:US
Practice Address - Phone:414-328-3800
Practice Address - Fax:414-328-3818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000001049Medicare PIN