Provider Demographics
NPI:1861750440
Name:WISCONSIN NEUROSURGERY SC
Entity type:Organization
Organization Name:WISCONSIN NEUROSURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBALL
Authorized Official - Middle Name:S
Authorized Official - Last Name:FUIKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-784-4205
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:17280 W NORTH AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4366
Practice Address - Country:US
Practice Address - Phone:262-784-4205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN NEUROSURGERY SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site