Provider Demographics
NPI:1518091016
Name:WISCONSIN NEUROSURGERY SC
Entity Type:Organization
Organization Name:WISCONSIN NEUROSURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBALL
Authorized Official - Middle Name:SANDS
Authorized Official - Last Name:FUIKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-784-4205
Mailing Address - Street 1:17280 W NORTH AVENUE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045
Mailing Address - Country:US
Mailing Address - Phone:262-784-4205
Mailing Address - Fax:262-784-6549
Practice Address - Street 1:17280 W NORTH AVENUE
Practice Address - Street 2:SUITE 204
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045
Practice Address - Country:US
Practice Address - Phone:262-784-4205
Practice Address - Fax:262-784-6549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32726207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI140007387OtherRAILROAD MEDICARE PIN
WI31768900Medicaid
WI4581860001OtherMEDICARE DMERC PIN
WI000101987Medicare PIN
WI000068219Medicare PIN
WI31768900Medicaid
WI000038280Medicare PIN
WIC87461Medicare UPIN
WI000268219Medicare PIN
WI4581860001Medicare NSC
WI000001987Medicare PIN
WI000068756Medicare ID - Type Unspecified