Provider Demographics
NPI:1295911618
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 1:2025 W OKLAHOMA AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4455
Mailing Address - Country:US
Mailing Address - Phone:414-647-0033
Mailing Address - Fax:414-647-0079
Practice Address - Street 1:5250 S 108TH ST
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-1331
Practice Address - Country:US
Practice Address - Phone:414-647-0033
Practice Address - Fax:414-647-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32685200Medicaid