Healthcare Provider Details

I. General information

NPI: 1508938606
Provider Name (Legal Business Name): BLOUNT ORTHOPAEDIC ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W RIVER WOODS PKWY STE 100
GLENDALE WI
53212-1010
US

IV. Provider business mailing address

525 W RIVER WOODS PKWY 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 TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JEAN M MARSICEK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 414-332-6262