Healthcare Provider Details

I. General information

NPI: 1295911618
Provider Name (Legal Business Name): SPORTS MEDICINE & ORTHOPEDIC CENTER, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 S 108TH ST
HALES CORNERS WI
53130-1331
US

IV. Provider business mailing address

2025 W OKLAHOMA AVE SUITE 100
MILWAUKEE WI
53215-4455
US

V. Phone/Fax

Practice location:
  • Phone: 414-647-0033
  • Fax: 414-647-0079
Mailing address:
  • Phone: 414-647-0033
  • Fax: 414-647-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM J PAUERS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 414-647-0033