Provider Demographics
NPI:1780821298
Name:WEST BEND CLINIC, INC.
Entity Type:Organization
Organization Name:WEST BEND CLINIC, INC.
Other - Org Name:FORWARD ORTHO
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:N
Authorized Official - Last Name:BROWNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-334-3451
Mailing Address - Street 1:1700 W PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9795
Mailing Address - Country:US
Mailing Address - Phone:262-334-3451
Mailing Address - Fax:262-306-2964
Practice Address - Street 1:W180N8085 TOWN HALL RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3518
Practice Address - Country:US
Practice Address - Phone:262-257-5860
Practice Address - Fax:262-257-5858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-21
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21251400Medicaid
WI4409930007Medicare NSC