Provider Demographics
NPI:1528038866
Name:SPINE NEUROSURGERY INST OF NE WI S.C.
Entity Type:Organization
Organization Name:SPINE NEUROSURGERY INST OF NE WI S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEREIRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-846-8057
Mailing Address - Street 1:3409 NICOLET DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7203
Mailing Address - Country:US
Mailing Address - Phone:920-846-8057
Mailing Address - Fax:920-846-4588
Practice Address - Street 1:835 S MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1282
Practice Address - Country:US
Practice Address - Phone:920-846-8057
Practice Address - Fax:920-846-4588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39920-20207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G72236Medicare UPIN
WI000043085Medicare PIN