Healthcare Provider Details

I. General information

NPI: 1760013890
Provider Name (Legal Business Name): WISCONSIN BONE & JOINT S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W RIVER WOODS PKWY STE 130
GLENDALE WI
53212-1010
US

IV. Provider business mailing address

2500 N MAYFAIR RD STE 500
WAUWATOSA WI
53226-1415
US

V. Phone/Fax

Practice location:
  • Phone: 414-961-0304
  • Fax: 414-961-2061
Mailing address:
  • Phone: 414-257-2525
  • Fax: 414-257-1772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DALE E BAUWENS
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 414-257-2525