Provider Demographics
NPI:1649430380
Name:FAMILY & SPORTS ORTHOPAEDIC CENTER, LLC
Entity type:Organization
Organization Name:FAMILY & SPORTS ORTHOPAEDIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUERST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-356-1000
Mailing Address - Street 1:118 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2104
Mailing Address - Country:US
Mailing Address - Phone:920-356-1000
Mailing Address - Fax:920-356-0719
Practice Address - Street 1:620 W BROWN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1702
Practice Address - Country:US
Practice Address - Phone:920-356-1000
Practice Address - Fax:920-356-0719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI15104OtherDEAN CARE
WI30082300Medicaid
WI11801OtherDEAN CARE
WI32123200Medicaid
WI11812OtherDEAN CARE
WI2033322OtherPHYSICIANS PLUS
WI36027400Medicaid
WI391796912OtherWPS
WI1003837OtherPHYSICIANS PLUS
WI2028274OtherPHYSICIANS PLUS
WI11801OtherDEAN CARE
WIGO6025Medicare UPIN
WI32123200Medicaid
WI16220Medicare PIN