Provider Demographics
NPI:1740217322
Name:BROD, STALEY A (MD)
Entity Type:Individual
Prefix:
First Name:STALEY
Middle Name:A
Last Name:BROD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF NEUROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5200
Mailing Address - Fax:414-259-0469
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF NEUROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5200
Practice Address - Fax:414-259-0469
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ09232084N0400X
WI653742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87X552OtherBCBS
WI1740217322Medicaid
TX129380505Medicaid
TX87X552OtherBCBS
TXE36863Medicare UPIN
WIK400287998Medicare PIN
TX87X552Medicare PIN