Healthcare Provider Details

I. General information

NPI: 1710053525
Provider Name (Legal Business Name): ORTHOPEDIC & SPINE THERAPY OF BRILLION, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MARITIME DR
MANITOWOC WI
54220-6826
US

IV. Provider business mailing address

4000 N PROVIDENCE AVE
APPLETON WI
54913-8018
US

V. Phone/Fax

Practice location:
  • Phone: 920-482-1516
  • Fax: 920-482-1581
Mailing address:
  • Phone: 920-257-2000
  • Fax: 920-257-2004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier41756800
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name: PAUL STEVEN BARNETT
Title or Position: OWNER-PRESIDENT
Credential: PT
Phone: 920-257-2000