1194984880 NPI number — FAMILY & SPORTS ORTHOPAEDIC CENTER, LLC

Table of content: (NPI 1194984880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194984880 NPI number — FAMILY & SPORTS ORTHOPAEDIC CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY & SPORTS ORTHOPAEDIC CENTER, LLC
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:
1194984880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
118 W MAPLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVER DAM
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53916-2104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-356-1000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1511 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53925-2401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-623-3012
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
COE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
920-356-1000

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1003837 . This is a "PHYSICIAN PLUS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 159462492004 . This is a "BCBS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 2028274 . This is a "PHYSICIANS PLUS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 11801 . This is a "DEAN CARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 2033322 . This is a "PHYSICIANS PLUS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 36027400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 391796912 . This is a "WPS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 43020200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15104 . This is a "DEAN CARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 30082300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15909 . This is a "DEAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 32123200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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