Provider Demographics
NPI:1215169073
Name:MILWAUKEE CLINIC OF ORTHO SURGERY LTD
Entity type:Organization
Organization Name:MILWAUKEE CLINIC OF ORTHO SURGERY LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BANACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-321-8960
Mailing Address - Street 1:5233 W MORGAN AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-1541
Mailing Address - Country:US
Mailing Address - Phone:414-321-8960
Mailing Address - Fax:414-321-0632
Practice Address - Street 1:19035 W CAPITOL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2755
Practice Address - Country:US
Practice Address - Phone:414-321-8960
Practice Address - Fax:414-321-0632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-12
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207X00000X, 213ES0103X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41716700Medicaid
WI0000068309Medicare NSC
WI1222470002Medicare NSC