Provider Demographics
NPI:1336733534
Name:MIDWEST SPINE CENTER SC
Entity Type:Organization
Organization Name:MIDWEST SPINE CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:STOLL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:414-807-6128
Mailing Address - Street 1:611 E LAKE HILL CT
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4351
Mailing Address - Country:US
Mailing Address - Phone:414-807-6128
Mailing Address - Fax:
Practice Address - Street 1:525 W RIVER WOODS PKWY STE 240
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212-1010
Practice Address - Country:US
Practice Address - Phone:414-807-6128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI26052OtherLICENSE