Healthcare Provider Details

I. General information

NPI: 1073506838
Provider Name (Legal Business Name): MCDONOUGH ORTHOPAEDIC AND SPORTS MEDICINE CENTER SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 03/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 DEWEY ST
WISCONSIN RAPIDS WI
54494-4715
US

IV. Provider business mailing address

PO BOX 8075
WISCONSIN RAPIDS WI
54495-8075
US

V. Phone/Fax

Practice location:
  • Phone: 715-421-5257
  • Fax: 715-421-0111
Mailing address:
  • Phone: 715-421-5257
  • Fax: 715-421-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. WAYNE R CHRISTIE
Title or Position: VICE PRESIDENT MCDONOUGH ORTHOPAEDI
Credential: MD
Phone: 715-421-5257