Provider Demographics
NPI:1760434336
Name:FITZGERALD, CAROL (OTR)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:SPINE CARE CLINIC AT PLANK ROAD
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3421
Mailing Address - Country:US
Mailing Address - Phone:414-955-7199
Mailing Address - Fax:414-955-0110
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:SPINE CARE CLINIC AT PLANK ROAD
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3421
Practice Address - Country:US
Practice Address - Phone:414-955-7199
Practice Address - Fax:414-955-0110
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1273-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
007806261BOtherHUMANA
WI40653600Medicaid
007806261BOtherHUMANA
WI736011690Medicare PIN