Provider Demographics
NPI: | 1760190243 |
---|---|
Name: | ORTHO SPORT & SPINE PHYSICIANS OF WISCONSIN |
Entity Type: | Organization |
Organization Name: | ORTHO SPORT & SPINE PHYSICIANS OF WISCONSIN |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | REVENUE CYCLE MANAGEMENT DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | FAITH |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BELTZHOOVER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 678-752-7246 |
Mailing Address - Street 1: | 5788 ROSWELL RD |
Mailing Address - Street 2: | |
Mailing Address - City: | ATLANTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30328-4904 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 678-752-7246 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2500 N MAYFAIR RD STE 440 |
Practice Address - Street 2: | |
Practice Address - City: | WAUWATOSA |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53226-1415 |
Practice Address - Country: | US |
Practice Address - Phone: | 678-752-7246 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2022-11-14 |
Last Update Date: | 2022-11-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Single Specialty |