Provider Demographics
NPI:1578516803
Name:THE NEUROSCIENCE GROUP OF NORTHEAST WISCONSIN SC
Entity Type:Organization
Organization Name:THE NEUROSCIENCE GROUP OF NORTHEAST WISCONSIN SC
Other - Org Name:NEUROSCIENCE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:YAZBAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-201-1194
Mailing Address - Street 1:1305 W AMERICAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1993
Mailing Address - Country:US
Mailing Address - Phone:800-201-1194
Mailing Address - Fax:920-720-7392
Practice Address - Street 1:1305 W. AMERICAN DRIVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-1993
Practice Address - Country:US
Practice Address - Phone:800-201-1194
Practice Address - Fax:920-720-7392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CD3987OtherRAILROAD MEDICARE
WI21284100Medicaid
WI000071450OtherMEDICARE
CD3987OtherRAILROAD MEDICARE
WI000071450OtherMEDICARE
000071450Medicare PIN