MEDICARE: SPINE SOLUTIONS OF GREEN BAY LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1700693884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE SOLUTIONS OF GREEN BAY LLC

Provider Business Mailing Address
First Line	:	DEPT CH 18031
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60055-8031
Country	:	US
Telephone Number	:	920-204-6758
Fax Number	:

Provider Business Practice Location Address
First Line	:	2595 DEVELOPMENT DR STE 150
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-4288
Country	:	US
Telephone Number	:	920-204-6758
Fax Number	:

Authorized Official
Title or Position	:	MD
Name	:	JEREMY ASHTON SCARLETT
Credential	:
Telephone Number	:	608-710-8162

Provider Enumeration Date	:	12/12/2024
Last Update Date	:	12/12/2024

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