Basic Information
| Provider Information | |||||||||
| NPI: | 1104142330 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN WISCONSIN BONE & JOINT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7520 HWY 51 S | ||||||||
| Address2: | |||||||||
| City: | MINOCQUA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545488943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153581911 | ||||||||
| FaxNumber: | 7153581912 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 S 7TH ST | ||||||||
| Address2: | |||||||||
| City: | ONTONAGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499531448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153581911 | ||||||||
| FaxNumber: | 7153581912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2010 | ||||||||
| LastUpdateDate: | 04/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | TADYCH | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7153581911 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1052540001 | 01 | DMERC NUMBER | OTHER | 000044000 | 01 | WI | MEDICARE ID-TYPE UNSPECIFIED | OTHER | 21298800 | 05 | WI | MEDICAID |