Basic Information
| Provider Information | |||||||||
| NPI: | 1558373977 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHLAND ORTHOPEDIC ASSOCIATES, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 E TIMBER DR | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545012852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153692300 | ||||||||
| FaxNumber: | 7153692482 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 E TIMBER DR | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545012852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153692300 | ||||||||
| FaxNumber: | 7153692482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 04/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | DYREBY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7153692300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | WI | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 43024500 | 05 | WI | MEDICAID | 32339000 | 05 | WI | MEDICAID | 42949500 | 05 | WI | MEDICAID | 34101900 | 05 | WI | MEDICAID | 30507700 | 05 | WI | MEDICAID | 34097900 | 05 | WI | MEDICAID |