Provider Demographics
NPI:1629035332
Name:RUPNOW, BRAD (PT)
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:
Last Name:RUPNOW
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1507
Mailing Address - Country:US
Mailing Address - Phone:608-417-6000
Mailing Address - Fax:
Practice Address - Street 1:2521 ALLEN BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-2211
Practice Address - Country:US
Practice Address - Phone:608-417-8025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007819225100000X
WI6515-024225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA934983415AMedicaid
WI40349800Medicaid
WI40349800Medicaid