Healthcare Provider Details

I. General information

NPI: 1477051753
Provider Name (Legal Business Name): SPINE CIN OF MILWAUKEE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 05/08/2021
Certification Date: 05/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E BUFFALO ST STE 206
MILWAUKEE WI
53202-5808
US

IV. Provider business mailing address

102 WOODMONT BLVD STE 350
NASHVILLE TN
37205-2216
US

V. Phone/Fax

Practice location:
  • Phone: 615-386-0064
  • Fax: 615-386-0067
Mailing address:
  • Phone: 615-386-0064
  • Fax: 615-386-0067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateWI

VIII. Authorized Official

Name: EDWARD LELAND HUTTON EADIE
Title or Position: DIRECTOR
Credential:
Phone: 615-733-2064