MEDICARE: MILWAUKEE SPINE AND JOINT CENTER

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	261Q00000X	Clinic/Center	4264-012	WI

General Provider Information

NPI Number	:	1821333550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILWAUKEE SPINE AND JOINT CENTER

Provider Business Mailing Address
First Line	:	1631 W LINCOLN AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-2637
Country	:	US
Telephone Number	:	414-643-9000
Fax Number	:	414-643-9004

Provider Business Practice Location Address
First Line	:	1631 W LINCOLN AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-2637
Country	:	US
Telephone Number	:	414-643-9000
Fax Number	:	414-643-9004

Authorized Official
Title or Position	:	CHIROPRACTOR-CLINIC DIRECTOR
Name	:	DR. KELLY WORTH
Credential	:	D.C.
Telephone Number	:	414-643-9000

Provider Enumeration Date	:	12/06/2012
Last Update Date	:	12/06/2012

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