Basic Information
| Provider Information | |||||||||
| NPI: | 1245294131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEYER | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | ALBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4425 N PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143193000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2311 N PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143193000 | ||||||||
| FaxNumber: | 4143193033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 32343 | WI | Y | Allopathic & Osteopathic Physicians | Surgery | 207RC0200X | 2006001559 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200634707 | 05 | MO | MEDICAID |