1437240421 NPI number — CLINIC OF ORTHOPEDIC SURGERY CHTD

Table of content: (NPI 1437240421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437240421 NPI number — CLINIC OF ORTHOPEDIC SURGERY CHTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINIC OF ORTHOPEDIC SURGERY CHTD
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:
1437240421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1358
Provider Second Line Business Mailing Address:
210 WISCONSIN AMERICAN DRIVE STE 235
Provider Business Mailing Address City Name:
FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54936-1358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-923-0641
Provider Business Mailing Address Fax Number:
920-923-3281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 WISCONSIN AMERICAN DR
Provider Second Line Business Practice Location Address:
STE 235
Provider Business Practice Location Address City Name:
FOND DU LAC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54935-2999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-923-0641
Provider Business Practice Location Address Fax Number:
920-923-3281
Provider Enumeration Date:
09/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROETKER
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
920-923-0641

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: 32745200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".