Healthcare Provider Details

I. General information

NPI: 1225954696
Provider Name (Legal Business Name): ORTHOPEDIC & SPORTS MEDICINE SPECIALISTS OF GREEN BAY, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 MEMORIAL DR
CHILTON WI
53014-1568
US

IV. Provider business mailing address

2223 LIME KILN RD STE 1
GREEN BAY WI
54311-6238
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-8113
  • Fax:
Mailing address:
  • Phone: 920-430-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SANDY FRAGALE
Title or Position: CEO
Credential:
Phone: 920-965-9520