=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225114218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINCOLN ORTHOPEDIC GROUP LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9400 W LINCOLN AVENUE
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-2306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-545-4646
-----------------------------------------------------
Fax | 414-545-5227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9400 W LINCOLN AVE
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-2306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-545-4646
-----------------------------------------------------
Fax | 414-545-5227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JEFFREY B. SHOVERS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 414-545-4646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204C00000X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
-----------------------------------------------------
License Number | 30083
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------