Provider Demographics
NPI:1043349566
Name:NORTHWOODS PHYSICAL THERAPY CLINIC & FITNESS CENTER INC
Entity Type:Organization
Organization Name:NORTHWOODS PHYSICAL THERAPY CLINIC & FITNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIEF PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MCCUSKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:715-634-2165
Mailing Address - Street 1:P.O. BOX 13018
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843
Mailing Address - Country:US
Mailing Address - Phone:715-634-2165
Mailing Address - Fax:715-634-1846
Practice Address - Street 1:15537 W HWY 77 EAST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843
Practice Address - Country:US
Practice Address - Phone:715-634-2165
Practice Address - Fax:715-634-1846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3070024225100000X
WI3070-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W10003647OtherTRICARE REGION CLAIMS
650013194OtherPALMETTO GBA
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