Provider Demographics
NPI:1720433790
Name:ORTHOPAEDIC ASSOCIATES OF WISCONSIN SC
Entity Type:Organization
Organization Name:ORTHOPAEDIC ASSOCIATES OF WISCONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MERKT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-303-5055
Mailing Address - Street 1:N15W28300 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-4800
Mailing Address - Country:US
Mailing Address - Phone:262-303-5055
Mailing Address - Fax:262-303-5057
Practice Address - Street 1:1231 S ROCHESTER ST STE 100
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149
Practice Address - Country:US
Practice Address - Phone:262-303-5055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207X00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0138000001Medicare NSC
WI0000068200Medicare PIN
WI0138000003Medicare NSC