Provider Demographics
NPI:1831144567
Name:LINDSTROM ORTHOPEDIC CLINIC, SC
Entity Type:Organization
Organization Name:LINDSTROM ORTHOPEDIC CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:LINDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-739-5755
Mailing Address - Street 1:2105 E ENTERPRISE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-739-5755
Mailing Address - Fax:920-739-5151
Practice Address - Street 1:2105 E ENTERPRISE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:APPLETON
Practice Address - State:WV
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-739-5755
Practice Address - Fax:920-739-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22441207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41708100OtherMEDICAID DME
WI30283000Medicaid
WI30283000Medicaid