Provider Demographics
NPI:1497519979
Name:PRISMA WISCONSIN LLC
Entity Type:Organization
Organization Name:PRISMA WISCONSIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WIENER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-939-1079
Mailing Address - Street 1:2031 RIDGE END RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1028
Mailing Address - Country:US
Mailing Address - Phone:206-939-1079
Mailing Address - Fax:206-785-1023
Practice Address - Street 1:13500 WATERTOWN PLANK RD STE 102
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2222
Practice Address - Country:US
Practice Address - Phone:206-785-1015
Practice Address - Fax:206-785-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty