Provider Demographics
NPI:1881183572
Name:ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JENIFER
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:TILLMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-560-1147
Mailing Address - Street 1:2105 E ENTERPRISE AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-991-2561
Mailing Address - Fax:920-991-2563
Practice Address - Street 1:2223 LIME KILN RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6213
Practice Address - Country:US
Practice Address - Phone:920-965-4715
Practice Address - Fax:920-569-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41174800Medicaid