Basic Information
Provider Information | |||||||||
NPI: | 1386828549 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHERN WISCONSIN BONE AND JOINT CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7520 US HIGHWAY 51 S | ||||||||
Address2: | STE A | ||||||||
City: | MINOCQUA | ||||||||
State: | WI | ||||||||
PostalCode: | 545488944 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7153581911 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 611 VETERANS PARKWAY | ||||||||
Address2: |   | ||||||||
City: | WOODRUFF | ||||||||
State: | WI | ||||||||
PostalCode: | 54568 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7153588600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/24/2007 | ||||||||
LastUpdateDate: | 02/22/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TADYCH | ||||||||
AuthorizedOfficialFirstName: | LISA | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | CORPORATE SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 7153581911 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | CQ2410 | 01 | WI | RAILROAD MEDICARE | OTHER | 1052540001 | 01 | WI | DMERC | OTHER | 000044000 | 01 | WI | MEDICARE ID | OTHER | 21298800 | 05 | WI |   | MEDICAID |