Provider Demographics
NPI:1639101405
Name:WISCONSIN NEUROLOGY CLINIC, LLC
Entity Type:Organization
Organization Name:WISCONSIN NEUROLOGY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRENDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MISRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-431-6760
Mailing Address - Street 1:2603 W RAWSON AVE
Mailing Address - Street 2:SUITE 128
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-8422
Mailing Address - Country:US
Mailing Address - Phone:414-431-6760
Mailing Address - Fax:414-431-6761
Practice Address - Street 1:2603 W RAWSON AVE
Practice Address - Street 2:SUITE 128
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8422
Practice Address - Country:US
Practice Address - Phone:414-431-6760
Practice Address - Fax:414-431-6761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI385802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32336900Medicaid