Basic Information
| Provider Information | |||||||||
| NPI: | 1063495000 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEUROSURGERY AND ENDOVASCULAR ASSOC. SC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SPINE AND BRAIN IMAGING CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 211037 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532211037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143858706 | ||||||||
| FaxNumber: | 4143858777 | ||||||||
| Practice Location | |||||||||
| Address1: | 10500 W LOOMIS RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531328030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143858700 | ||||||||
| FaxNumber: | 4143852799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AHUJA | ||||||||
| AuthorizedOfficialFirstName: | ARVIND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | NEUROSURGEON | ||||||||
| AuthorizedOfficialTelephone: | 4143858706 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471C3401X | N | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Computed Tomography | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QM1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | 21286600 | 05 | WI | MEDICAID |