1750374575 NPI number — MCDONOUGH ORTHOPAEDIC AND SPORTS MEDICINE CENTER SC

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 1750374575 NPI number — MCDONOUGH ORTHOPAEDIC AND SPORTS MEDICINE CENTER SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCDONOUGH ORTHOPAEDIC AND SPORTS MEDICINE CENTER SC
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:
1750374575
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8075
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WISCONSIN RAPIDS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54495-8075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-421-5255
Provider Business Mailing Address Fax Number:
715-421-0111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 DEWEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WISCONSIN RAPIDS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54494-4715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-421-5257
Provider Business Practice Location Address Fax Number:
715-421-0111
Provider Enumeration Date:
08/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTIE
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
715-421-5257

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 32685600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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