Provider Demographics
NPI:1760670145
Name:ORTHOPEDIC & SPORTS MEDICINE SPECIALISTS OF GREEN BAY, SC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPORTS MEDICINE SPECIALISTS OF GREEN BAY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER CREDENTIALING AND PRIVILEG
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KLAUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-965-9517
Mailing Address - Street 1:2223 LIME KILN RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6213
Mailing Address - Country:US
Mailing Address - Phone:920-430-8120
Mailing Address - Fax:920-430-8122
Practice Address - Street 1:2223 LIME KILN RD
Practice Address - Street 2:SUITE 1
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6213
Practice Address - Country:US
Practice Address - Phone:920-430-8120
Practice Address - Fax:920-430-8122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21316600Medicaid
WI6206770001Medicare NSC
WI000007027Medicare PIN