Provider Demographics
NPI:1710395959
Name:ORTHOPEDIC ASSOCIATES OF WISCONSIN
Entity Type:Organization
Organization Name:ORTHOPEDIC ASSOCIATES OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-544-5311
Mailing Address - Street 1:512 N 109TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4210
Mailing Address - Country:US
Mailing Address - Phone:702-572-2583
Mailing Address - Fax:
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-544-5311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1442-39261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center