Basic Information
| Provider Information | |||||||||
| NPI: | 1073026993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILDCAT NEUROPHYSIOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 733955 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753733955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843518459 | ||||||||
| FaxNumber: | 4843518810 | ||||||||
| Practice Location | |||||||||
| Address1: | 41 UNIVERSITY DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189401873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843518459 | ||||||||
| FaxNumber: | 4843518810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2017 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | FRIED | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4843518459 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | DE | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
No ID Information.