Provider Demographics
NPI:1073506838
Name:MCDONOUGH ORTHOPAEDIC AND SPORTS MEDICINE CENTER SC
Entity Type:Organization
Organization Name:MCDONOUGH ORTHOPAEDIC AND SPORTS MEDICINE CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT MCDONOUGH ORTHOPAEDI
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHRISTIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-421-5257
Mailing Address - Street 1:PO BOX 8075
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-8075
Mailing Address - Country:US
Mailing Address - Phone:715-421-5257
Mailing Address - Fax:715-421-0111
Practice Address - Street 1:410 DEWEY ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4715
Practice Address - Country:US
Practice Address - Phone:715-421-5257
Practice Address - Fax:715-421-0111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCDONOUGH ORTHOPAEDIC AND SPORTS MEDICINE CENTER SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-26
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI416963000Medicaid
WI477980001Medicare ID - Type Unspecified