Provider Demographics
NPI:1801991468
Name:OSTEOPATHIC MEDICINE & PHYSICAL THERAPY GRP OF NORTHEAST WISCONSIN
Entity type:Organization
Organization Name:OSTEOPATHIC MEDICINE & PHYSICAL THERAPY GRP OF NORTHEAST WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MAROTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:920-733-7726
Mailing Address - Street 1:626 E LONGVIEW DR STE B
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-2149
Mailing Address - Country:US
Mailing Address - Phone:920-733-7726
Mailing Address - Fax:920-939-3060
Practice Address - Street 1:1010 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-7802
Practice Address - Country:US
Practice Address - Phone:920-733-7726
Practice Address - Fax:920-733-2109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30330Medicare ID - Type Unspecified