Provider Demographics
NPI:1073678215
Name:SCOLMAN, GREGORY (PT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:SCOLMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3100
Mailing Address - Country:US
Mailing Address - Phone:920-563-9357
Mailing Address - Fax:
Practice Address - Street 1:1504 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538
Practice Address - Country:US
Practice Address - Phone:920-563-9357
Practice Address - Fax:920-568-6545
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3676-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3676-024OtherPT LICENSE NUMBER
WI36104100Medicare ID - Type UnspecifiedPYSICAL THERAPY PROVIDER