Provider Demographics
NPI:1861638900
Name:SPORT & SPINE CLINIC OF FORT ATKINSON LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:SPORT & SPINE CLINIC OF FORT ATKINSON LIMITED PARTNERSHIP
Other - Org Name:SPORT & SPINE CLINIC OF MADISON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LAWRANCE
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCAFEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-297-7000
Mailing Address - Street 1:340 S WHITNEY WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4656
Mailing Address - Country:US
Mailing Address - Phone:608-238-1312
Mailing Address - Fax:608-238-1464
Practice Address - Street 1:340 S WHITNEY WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4656
Practice Address - Country:US
Practice Address - Phone:608-238-1312
Practice Address - Fax:608-238-1464
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPORT & SPINE CLINIC OF FORT ATKINSON LIMITED PARTNERSHIP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-19
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5319850002Medicare NSC