Provider Demographics
NPI:1649008004
Name:NEUROLOGY DIAGNOSTICS GROUP, PLLC
Entity type:Organization
Organization Name:NEUROLOGY DIAGNOSTICS GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING & CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-875-6575
Mailing Address - Street 1:626 W MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2433
Mailing Address - Country:US
Mailing Address - Phone:866-374-7648
Mailing Address - Fax:
Practice Address - Street 1:117 NE TRILEIN DR
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-2082
Practice Address - Country:US
Practice Address - Phone:866-374-7648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty