Provider Demographics
NPI:1437240421
Name:CLINIC OF ORTHOPEDIC SURGERY CHTD
Entity Type:Organization
Organization Name:CLINIC OF ORTHOPEDIC SURGERY CHTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROETKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-923-0641
Mailing Address - Street 1:PO BOX 1358
Mailing Address - Street 2:210 WISCONSIN AMERICAN DRIVE STE 235
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54936-1358
Mailing Address - Country:US
Mailing Address - Phone:920-923-0641
Mailing Address - Fax:920-923-3281
Practice Address - Street 1:210 WISCONSIN AMERICAN DR
Practice Address - Street 2:STE 235
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2999
Practice Address - Country:US
Practice Address - Phone:920-923-0641
Practice Address - Fax:920-923-3281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32745200Medicaid