Provider Demographics
NPI:1346355252
Name:WISCONSIN PROSTHETICS & ORTHOTICS INC
Entity Type:Organization
Organization Name:WISCONSIN PROSTHETICS & ORTHOTICS INC
Other - Org Name:NOVACARE PROSTHETICS & ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:TARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-972-1100
Mailing Address - Street 1:4714 GETTYSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-4325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1344 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3042
Practice Address - Country:US
Practice Address - Phone:920-803-9610
Practice Address - Fax:920-803-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41792100Medicaid
WI0247690003Medicare NSC