MEDICARE: ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist
2	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1639661119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC

Provider Business Mailing Address
First Line	:	2105 E ENTERPRISE AVE STE 113
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54913-7862
Country	:	US
Telephone Number	:	920-560-1083
Fax Number	:	920-560-1098

Provider Business Practice Location Address
First Line	:	1931 MARINETTE AVE
Second Line	:
City	:	MARINETTE
State	:	WI
Zip	:	54143-3801
Country	:	US
Telephone Number	:	715-735-5500
Fax Number	:	715-735-5502

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	CAMILLA MEYER
Credential	:
Telephone Number	:	920-393-2819

Provider Enumeration Date	:	05/31/2018
Last Update Date	:	12/18/2025

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