=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952418816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPEDIC & SPINE THERAPY OF OSHKOSH SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 06/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 S WASHBURN ST STE 100
-----------------------------------------------------
City | OSHKOSH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54904-7951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-232-4040
-----------------------------------------------------
Fax | 920-232-4042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 MIDWAY RD
-----------------------------------------------------
City | MENASHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54952-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-257-2000
-----------------------------------------------------
Fax | 920-257-2004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | VICTORIA WALBRUN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-257-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------