Provider Demographics
NPI:1366710584
Name:ATHLETIC AND THERAPEUTIC INSTITUTE OF MILWAUKEE, LLC
Entity type:Organization
Organization Name:ATHLETIC AND THERAPEUTIC INSTITUTE OF MILWAUKEE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGIVERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-296-2222
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:5502 WASHINGTON AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4093
Practice Address - Country:US
Practice Address - Phone:262-637-2470
Practice Address - Fax:262-637-2532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1366710584Medicaid
WI1366710584Medicaid