Provider Demographics
NPI:1669584983
Name:ORTHOPAEDIC HOSPITAL OF WISCONSIN, LLC
Entity type:Organization
Organization Name:ORTHOPAEDIC HOSPITAL OF WISCONSIN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:G
Authorized Official - Last Name:GOLDBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-961-6846
Mailing Address - Street 1:475 W RIVER WOODS PKWY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1081
Mailing Address - Country:US
Mailing Address - Phone:414-961-6800
Mailing Address - Fax:414-961-6778
Practice Address - Street 1:475 W RIVER WOODS PKWY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212-1081
Practice Address - Country:US
Practice Address - Phone:414-961-6800
Practice Address - Fax:414-961-6778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1006282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
7375295OtherAETNA PIN
2076664OtherUNITED HEALTH CARE
137685900OtherU.S. DEPT. OF LABOR
IN200490820AMedicaid
WI11023600Medicaid
137685900OtherU.S. DEPT. OF LABOR
=========OtherAETNA
=========OtherCHAMPUS/TRICARE
IN200490820AMedicaid
=========OtherCHAMPUS/TRICARE