Provider Demographics
NPI:1225296874
Name:INTEGRATED SPORT AND SPINE CLINIC OF MADISON LLC
Entity Type:Organization
Organization Name:INTEGRATED SPORT AND SPINE CLINIC OF MADISON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HEITMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:608-271-8009
Mailing Address - Street 1:3109 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-1447
Mailing Address - Country:US
Mailing Address - Phone:608-271-8009
Mailing Address - Fax:608-243-9290
Practice Address - Street 1:3109 COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-1447
Practice Address - Country:US
Practice Address - Phone:608-271-8009
Practice Address - Fax:608-243-9290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4401-12261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty