Healthcare Provider Details

I. General information

NPI: 1104621044
Provider Name (Legal Business Name): SPINE CAPITAL WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2025
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E ENTERPRISE AVE FL 2
APPLETON WI
54913-7862
US

IV. Provider business mailing address

2105 E ENTERPRISE AVE
APPLETON WI
54913-7862
US

V. Phone/Fax

Practice location:
  • Phone: 920-333-8878
  • Fax:
Mailing address:
  • Phone: 920-333-8878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT KOFFIE
Title or Position: CEO
Credential: MD
Phone: 812-756-8888