Provider Demographics
NPI:1396914214
Name:NORTHERN WISCONSIN BONE & JOINT CENTER, LTD
Entity type:Organization
Organization Name:NORTHERN WISCONSIN BONE & JOINT CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TADYCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-358-1911
Mailing Address - Street 1:7520 US HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-8943
Mailing Address - Country:US
Mailing Address - Phone:715-358-1911
Mailing Address - Fax:715-358-6158
Practice Address - Street 1:1630 N CHIPPEWA DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501
Practice Address - Country:US
Practice Address - Phone:715-361-5480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29520-020207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1052540001OtherDMERC
WICQ2410OtherRR MEDICARE
WI21298800Medicaid
WI1052540001OtherDMERC
WI1052540001OtherDMERC