Provider Demographics
NPI:1548422082
Name:ORTHOPEDIC & SPINE THERAPY OF STURGEON BAY, SC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPINE THERAPY OF STURGEON BAY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:BARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:920-257-2000
Mailing Address - Street 1:4000 N PROVIDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8018
Mailing Address - Country:US
Mailing Address - Phone:920-257-2000
Mailing Address - Fax:920-257-2004
Practice Address - Street 1:228 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1318
Practice Address - Country:US
Practice Address - Phone:920-746-3180
Practice Address - Fax:920-746-3182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-10-10
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
WI36191300Medicaid
WI613446600OtherUS DEPT OF LABOR
WI000017151OtherPTAN
WI000017151OtherPTAN