Provider Demographics
NPI:1710093968
Name:NEUROLOGIC ASSOCIATES OF WISCONSIN LTD
Entity Type:Organization
Organization Name:NEUROLOGIC ASSOCIATES OF WISCONSIN LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOBLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-542-0074
Mailing Address - Street 1:1111 DELAFIELD ST STE 105
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3402
Mailing Address - Country:US
Mailing Address - Phone:262-542-9503
Mailing Address - Fax:262-522-7286
Practice Address - Street 1:1111 DELAFIELD ST STE 105
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3402
Practice Address - Country:US
Practice Address - Phone:262-542-9503
Practice Address - Fax:262-522-7286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6022220001Medicare NSC