Provider Demographics
NPI:1558477307
Name:ORTHOPEDIC & SPINE THERAPY OF GREEN BAY, SC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPINE THERAPY OF GREEN 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 AVENUE
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 1:211 N BROADWAY STE 105
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2757
Practice Address - Country:US
Practice Address - Phone:920-432-9040
Practice Address - Fax:920-432-9053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40415100Medicaid
WI41745600Medicaid
WI369376100OtherUS DEPARTMENT OF LABOR
WICI9565OtherRAILROAD MEDICARE
WI40415100Medicaid
WI369376100OtherUS DEPARTMENT OF LABOR
WI0945870001Medicare NSC