Provider Demographics
NPI:1922334101
Name:ORTHOPEDIC SURGERY CENTER OF GREEN BAY, LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC SURGERY CENTER OF GREEN BAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAGALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-965-9520
Mailing Address - Street 1:2223 LIME KILN RD STE 1
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6213
Mailing Address - Country:US
Mailing Address - Phone:920-965-9520
Mailing Address - Fax:920-430-8122
Practice Address - Street 1:2223 LIME KILN RD STE 2
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:920-965-9520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QA1903X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical