Healthcare Provider Details

I. General information

NPI: 1225114218
Provider Name (Legal Business Name): LINCOLN ORTHOPEDIC GROUP LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 W LINCOLN AVENUE
WEST ALLIS WI
53227-2306
US

IV. Provider business mailing address

9400 W LINCOLN AVE
WEST ALLIS WI
53227-2306
US

V. Phone/Fax

Practice location:
  • Phone: 414-545-4646
  • Fax: 414-545-5227
Mailing address:
  • Phone: 414-545-4646
  • Fax: 414-545-5227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number30083
License Number StateWI

VIII. Authorized Official

Name: DR. JEFFREY B. SHOVERS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 414-545-4646