Provider Demographics
NPI:1164510061
Name:ORTHOPEDIC & SPINE THERAPY OF MENASHA, SC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPINE THERAPY OF MENASHA, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:BARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:920-257-2000
Mailing Address - Street 1:4000 N PROVIDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8018
Mailing Address - Country:US
Mailing Address - Phone:920-257-2000
Mailing Address - Fax:920-257-2004
Practice Address - Street 1:730 MIDWAY ROAD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1014
Practice Address - Country:US
Practice Address - Phone:920-727-9878
Practice Address - Fax:920-727-9903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41745500Medicaid
WI5335410001Medicare NSC