Healthcare Provider Details

I. General information

NPI: 1740468693
Provider Name (Legal Business Name): ORTHOPAEDIC & SPORTS MEDICINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2008
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CLAY ST
DARLINGTON WI
53530-1228
US

IV. Provider business mailing address

800 CLAY ST
DARLINGTON WI
53530-1228
US

V. Phone/Fax

Practice location:
  • Phone: 608-776-4466
  • Fax:
Mailing address:
  • Phone: 608-776-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number27334
License Number StateWI

VIII. Authorized Official

Name: DANIEL M STORMONT
Title or Position: PRESIDENT
Credential: MD
Phone: 608-776-4466