Healthcare Provider Details

I. General information

NPI: 1245212414
Provider Name (Legal Business Name): INTEGRATED SPINE CARE, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N 99TH ST SUITE 101
WAUWATOSA WI
53226-4339
US

IV. Provider business mailing address

601 N 99TH ST SUITE 101
WAUWATOSA WI
53226-4339
US

V. Phone/Fax

Practice location:
  • Phone: 414-988-5100
  • Fax: 414-988-5102
Mailing address:
  • Phone: 414-988-5100
  • Fax: 414-988-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number574150-9
License Number StateWI

VIII. Authorized Official

Name: CLAY JAMISON FRANK
Title or Position: PRESIDENT
Credential: MD
Phone: 414-988-5100