MEDICARE: SPORT CLINIC OF GREATER MILWAUKEE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275628208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORT CLINIC OF GREATER MILWAUKEE

Provider Business Mailing Address
First Line	:	11904 W NORTH AVE
Second Line	:	STE 100
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2062
Country	:	US
Telephone Number	:	414-453-8616
Fax Number	:	414-453-6150

Provider Business Practice Location Address
First Line	:	11904 W NORTH AVE
Second Line	:	STE 100
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2062
Country	:	US
Telephone Number	:	414-453-8616
Fax Number	:	414-453-6150

Authorized Official
Title or Position	:	C.F.O.
Name	:	MR. MATTHEW BECKER
Credential	:
Telephone Number	:	414-453-8616

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/22/2020

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