Provider Demographics
NPI:1952585432
Name:SPORTS MEDICINE & ORTHOPEDIC CENTER, S.C.
Entity Type:Organization
Organization Name:SPORTS MEDICINE & ORTHOPEDIC CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:PAUERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-647-0033
Mailing Address - Street 1:3033 W LAYTON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2628
Mailing Address - Country:US
Mailing Address - Phone:414-647-0033
Mailing Address - Fax:414-647-0079
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:SUITE 418
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-7767
Practice Address - Fax:414-328-8127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32685200Medicaid
WI000001621Medicare PIN
WI32685200Medicaid