Provider Demographics
NPI:1215471461
Name:THE NEUROSCIENCE GROUP OF NORTHEAST WISCONSIN, SC
Entity type:Organization
Organization Name:THE NEUROSCIENCE GROUP OF NORTHEAST WISCONSIN, SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SURGEON/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:YAZBAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-201-1194
Mailing Address - Street 1:1305 W AMERICAN DR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1993
Mailing Address - Country:US
Mailing Address - Phone:800-201-1194
Mailing Address - Fax:920-720-7392
Practice Address - Street 1:1305 W AMERICAN DR
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-1993
Practice Address - Country:US
Practice Address - Phone:800-201-1194
Practice Address - Fax:920-720-7392
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE NEUROSCIENCE GROUP OF NORTHEAST WISCONSIN, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21284100Medicaid