Healthcare Provider Details

I. General information

NPI: 1831194448
Provider Name (Legal Business Name): BLOUNT ORTHOPAEDIC ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W. RIVER WOODS PARKWAY SUITE 100
GLENDALE WI
53212-1010
US

IV. Provider business mailing address

525 W. RIVER WOODS PARKWAY SUITE 100
GLENDALE WI
53212-1010
US

V. Phone/Fax

Practice location:
  • Phone: 414-332-6262
  • Fax: 414-332-0422
Mailing address:
  • Phone: 414-332-6262
  • Fax: 414-332-0422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: JEAN MARIE MARSICEK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 414-977-1325