Provider Demographics
NPI:1659436368
Name:ATHLETIC AND THERAPEUTIC INSTITUTE OF MILWAUKEE, LLC
Entity Type:Organization
Organization Name:ATHLETIC AND THERAPEUTIC INSTITUTE OF MILWAUKEE, LLC
Other - Org Name:ATHLETIC AND THERAPEUTIC INSTITUTE OF NEW BERLIN, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-296-2222
Mailing Address - Street 1:4947 PAYSHERE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-4064
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-6106
Practice Address - Street 1:15312 W BELOIT ROAD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151
Practice Address - Country:US
Practice Address - Phone:262-641-5771
Practice Address - Fax:262-641-6317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41231600Medicaid
WI611826603OtherDEPARTMENT OF LABOR PROVIDER NUMBER
WI0000083042Medicare PIN