Provider Demographics
NPI:1700217205
Name:FUSION PHYSICAL THERAPY AND WELLNESS
Entity Type:Organization
Organization Name:FUSION PHYSICAL THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCATORATE PHYSICAL THERAPY
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:414-412-8072
Mailing Address - Street 1:PO BOX 170826
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-8076
Mailing Address - Country:US
Mailing Address - Phone:414-412-8072
Mailing Address - Fax:
Practice Address - Street 1:N49W6693 WESTERN RD
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-1804
Practice Address - Country:US
Practice Address - Phone:414-412-8072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10888-24261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659565133Medicaid
WI000085185Medicare PIN
WI1659565133Medicaid