Provider Demographics
NPI:1437323961
Name:ORTHOPEDIC & SPORTS THERAPY SC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPORTS THERAPY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:262-549-1118
Mailing Address - Street 1:S22W22660 BROADWAY
Mailing Address - Street 2:#3A
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-8100
Mailing Address - Country:US
Mailing Address - Phone:262-549-1118
Mailing Address - Fax:262-549-1118
Practice Address - Street 1:S22W22660 BROADWAY
Practice Address - Street 2:#3A
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-8100
Practice Address - Country:US
Practice Address - Phone:262-549-1118
Practice Address - Fax:262-549-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
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
WI40023900Medicaid