Provider Demographics
NPI:1245294131
Name:MEYER, NICHOLAS ALBERT (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALBERT
Last Name:MEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-319-3000
Mailing Address - Fax:
Practice Address - Street 1:2311 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4445
Practice Address - Country:US
Practice Address - Phone:414-319-3000
Practice Address - Fax:414-319-3033
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32343208600000X
MO2006001559207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200634707Medicaid
MOP00422539Medicare PIN
MO200634707Medicaid
MO939191875Medicare PIN
MO939195236Medicare PIN
MOG34693Medicare UPIN