FAMILY & SPORTS ORTHOPAEDIC CENTER, LLC

Provider Demographics

• NPI: 1467565978
• Name: FAMILY & SPORTS ORTHOPAEDIC CENTER, LLC
• Entity Type: Organization
• Organization Name: FAMILY & SPORTS ORTHOPAEDIC CENTER, LLC
• Authorized Official - Title/Position: MEMBER
• Authorized Official - Prefix: DR
• Authorized Official - First Name: ROBERT
• Authorized Official - Middle Name: A
• Authorized Official - Last Name: COE
• Authorized Official - Credentials: MD
• Authorized Official - Phone: 920-356-1000
• Mailing Address - Street 1: 118 W MAPLE AVE
• Mailing Address - City: BEAVER DAM
• Mailing Address - State: WI
• Mailing Address - Zip Code: 53916-2104
• Mailing Address - Country: US
• Mailing Address - Phone: 920-356-1000
• Mailing Address - Fax: 920-356-0719
• Practice Address - Street 1: 118 W MAPLE AVE
• Practice Address - City: BEAVER DAM
• Practice Address - State: WI
• Practice Address - Zip Code: 53916-2104
• Practice Address - Country: US
• Practice Address - Phone: 920-356-1000
• Practice Address - Fax: 920-356-0719
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-08-17
• Last Update Date: 2011-03-02

Provider Licenses

State	License ID	Taxonomies
WI	36330	174400000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	174400000X	Other Service Providers	Specialist		Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
WI	11801	Other	DEAN
WI	391796912	Other	WPS
WI	40349200	Medicaid
WI	13843	Other	DEAN
WI	15909	Other	DEAN
WI	30821700	Medicaid
WI	1003837	Other	PHYSICIANS PLUS
WI	1034219	Other	PHYSICIANS PLUS
WI	15104	Other	DEAN
WI	30082300	Medicaid
WI	36027400	Medicaid
WI	40452200	Medicaid
WI	1002676	Other	PHYSICIANS PLUS
WI	2033322	Other	PHYSICIANS PLUS
WI	32123200	Medicaid
WI	2028274	Other	PHYSICIANS PLUS
WI	43020200	Medicaid
WI	000381051	Medicare PIN
WI	1002676	Other	PHYSICIANS PLUS
WI	2028274	Other	PHYSICIANS PLUS
WI	EO8745	Medicare UPIN
WI	200033640	Medicare PIN
WI	1003837	Other	PHYSICIANS PLUS
WI	43020200	Medicaid
WI	30082300	Medicaid
WI	2033322	Other	PHYSICIANS PLUS
WI	000381043	Medicare PIN
WI	000281043	Medicare PIN
WI	11801	Other	DEAN
	Q76381	Medicare UPIN
WI	1237790001	Medicare NSC
WI	200033350	Medicare PIN
WI	000816220	Medicare PIN