Provider Demographics
NPI:1386828549
Name:NORTHERN WISCONSIN BONE AND JOINT CENTER
Entity Type:Organization
Organization Name:NORTHERN WISCONSIN BONE AND JOINT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TADYCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-358-1911
Mailing Address - Street 1:7520 US HIGHWAY 51 S
Mailing Address - Street 2:STE A
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-8944
Mailing Address - Country:US
Mailing Address - Phone:715-358-1911
Mailing Address - Fax:
Practice Address - Street 1:611 VETERANS PARKWAY
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568
Practice Address - Country:US
Practice Address - Phone:715-358-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICQ2410OtherRAILROAD MEDICARE
WI1052540001OtherDMERC
WI000044000OtherMEDICARE ID
WI21298800Medicaid
WICQ2410OtherRAILROAD MEDICARE
WI=========010OtherBCBS