Basic Information
| Provider Information | |||||||||
| NPI: | 1982072773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAIG | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | GINA | ||||||||
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| OtherCredential: | PT, DPT, CSCS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 202 S PARK STREET | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53715 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2521 ALLEN BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084173370 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2015 | ||||||||
| LastUpdateDate: | 09/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 13118-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.