MEDICARE: JOHN OCHSENWALD ATC

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	2255A2300X	Athletic Trainer	123-39	WI

General Provider Information

NPI Number	:	1659673085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN OCHSENWALD ATC

Provider Business Mailing Address
First Line	:	N108W6989 BERKSHIRE ST
Second Line	:
City	:	CEDARBURG
State	:	WI
Zip	:	53012-1277
Country	:	US
Telephone Number	:	262-375-2424
Fax Number	:	262-375-9465

Provider Business Practice Location Address
First Line	:	3409 N DOWNER AVE
Second Line	:	PAV 250, SPORTS MEDICINE
City	:	MILWAUKEE
State	:	WI
Zip	:	53211
Country	:	US
Telephone Number	:	414-229-6572
Fax Number	:	414-229-6671

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2010
Last Update Date	:	11/17/2010

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