Provider Demographics
NPI:1821105354
Name:ORTHOPEDIC & SPINE THERAPY OF CLINTONVILLE, SC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPINE THERAPY OF CLINTONVILLE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:BARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-257-2000
Mailing Address - Street 1:4000 N. PROVIDENCE AVENUE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8018
Mailing Address - Country:US
Mailing Address - Phone:920-257-2000
Mailing Address - Fax:920-257-2004
Practice Address - Street 1:205 W GREEN BAY ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2333
Practice Address - Country:US
Practice Address - Phone:715-526-5433
Practice Address - Fax:715-526-6930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI128873OtherHEALTH PARTNERS
WI41746200Medicaid
WI1019870005OtherAMERICHOICE
WICH3959OtherRAILROAD MEDICARE
WI40423300Medicaid
WI=========026OtherBCBS OF WI
WI128873OtherHEALTH PARTNERS