1073026993 NPI number — WILDCAT NEUROPHYSIOLOGY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073026993 NPI number — WILDCAT NEUROPHYSIOLOGY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILDCAT NEUROPHYSIOLOGY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073026993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1141 N LOOP 1604 E STE 105-484
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78232-1339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-351-8459
Provider Business Mailing Address Fax Number:
484-351-8810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 FRONT ST STE 280
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONSHOHOCKEN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19428-2891
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-351-8459
Provider Business Practice Location Address Fax Number:
484-351-8810
Provider Enumeration Date:
11/14/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FRIED
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
484-351-8459

Provider Taxonomy Codes

  • Taxonomy code: 204D00000X , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)