Provider Demographics
NPI:1841451622
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 1:1515 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1618
Practice Address - Country:US
Practice Address - Phone:920-623-3012
Practice Address - Fax:920-623-3059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2028274OtherPHYSICIANS PLUS
WI2033322OtherPHYSICIANS PLUS
WI36027400Medicaid
WI1003837OtherPHYSICIANS PLUS
WI11801OtherDEAN CARE
WI11812OtherDEAN CARE
WI15104OtherDEAN CARE
WI30082300Medicaid
WI32123200Medicaid
WI391796912OtherWPS
WI30082300Medicaid
WI2028274OtherPHYSICIANS PLUS
WI11812OtherDEAN CARE
WI2033322OtherPHYSICIANS PLUS
WIGO6025Medicare UPIN