Provider Demographics
NPI:1821048844
Name:SCANDIN, MICHAEL JOHN (PT LAT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:SCANDIN
Suffix:
Gender:M
Credentials:PT LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1349
Mailing Address - Street 2:SPORT & SPINE CLINIC
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54402-1349
Mailing Address - Country:US
Mailing Address - Phone:715-845-2942
Mailing Address - Fax:715-842-3416
Practice Address - Street 1:16 E MENARD PLAZA
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401
Practice Address - Country:US
Practice Address - Phone:715-845-2942
Practice Address - Fax:715-842-3416
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3841024225100000X
WI5400392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4180500Medicaid
WI29129OtherSECURITY HEALTH
WI4180500Medicaid