Provider Demographics
NPI:1780628925
Name:VALLEY ORTHOPEDIC CLINIC SC
Entity Type:Organization
Organization Name:VALLEY ORTHOPEDIC CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-731-6611
Mailing Address - Street 1:2105 E ENTERPRISE AVE
Mailing Address - Street 2:STE 111
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-731-6611
Mailing Address - Fax:920-731-6732
Practice Address - Street 1:2105 E ENTERPRISE AVE
Practice Address - Street 2:STE 111
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-731-6611
Practice Address - Fax:920-731-6732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32748000Medicaid
WI32748000Medicaid
WI0272900001Medicare NSC