Provider Demographics
NPI:1194984880
Name:FAMILY & SPORTS ORTHOPAEDIC CENTER, LLC
Entity type:Organization
Organization Name:FAMILY & SPORTS ORTHOPAEDIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:COE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-356-1000
Mailing Address - Street 1:118 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2104
Mailing Address - Country:US
Mailing Address - Phone:920-356-1000
Mailing Address - Fax:
Practice Address - Street 1:1511 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-2401
Practice Address - Country:US
Practice Address - Phone:920-623-3012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003837OtherPHYSICIAN PLUS
WI159462492004OtherBCBS
WI2028274OtherPHYSICIANS PLUS
WI11801OtherDEAN CARE
WI2033322OtherPHYSICIANS PLUS
WI36027400Medicaid
WI391796912OtherWPS
WI43020200Medicaid
WI15104OtherDEAN CARE
WI30082300Medicaid
WI15909OtherDEAN
WI32123200Medicaid
WI200033641Medicare PIN
WI1003837OtherPHYSICIAN PLUS
WI30082300Medicaid
WIWI1856001Medicare PIN
WIQ76381Medicare UPIN
WI2028274OtherPHYSICIANS PLUS
WI1237790002Medicare NSC
WIWI1856003Medicare PIN
WIWI1856002Medicare PIN