Provider Demographics
NPI:1154002491
Name:PHYSICAL MEDICAL ASSOCIATES OF WISCONSIN SC
Entity type:Organization
Organization Name:PHYSICAL MEDICAL ASSOCIATES OF WISCONSIN SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KORTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-340-8740
Mailing Address - Street 1:PO BOX 680
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-0680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5535 NOBEL DR
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-4955
Practice Address - Country:US
Practice Address - Phone:999-999-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-28
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty