Provider Demographics
NPI:1285478743
Name:WISCONSIN ORTHOPEDIC PHYSICAL THERAPY
Entity type:Organization
Organization Name:WISCONSIN ORTHOPEDIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:414-763-2941
Mailing Address - Street 1:3825 N KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-6397
Mailing Address - Country:US
Mailing Address - Phone:312-654-3939
Mailing Address - Fax:
Practice Address - Street 1:590 W NORTH SHORE DR
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-8312
Practice Address - Country:US
Practice Address - Phone:414-763-2941
Practice Address - Fax:414-930-4739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty