Provider Demographics
NPI:1275628208
Name:SPORT CLINIC OF GREATER MILWAUKEE
Entity Type:Organization
Organization Name:SPORT CLINIC OF GREATER MILWAUKEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.F.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-453-8616
Mailing Address - Street 1:11904 W NORTH AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2062
Mailing Address - Country:US
Mailing Address - Phone:414-453-8616
Mailing Address - Fax:414-453-6150
Practice Address - Street 1:11904 W NORTH AVE
Practice Address - Street 2:STE 100
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2062
Practice Address - Country:US
Practice Address - Phone:414-453-8616
Practice Address - Fax:414-453-6150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40418200Medicaid