Provider Demographics
NPI:1407857790
Name:ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC
Entity type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILBUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-560-1194
Mailing Address - Street 1:2105 E ENTERPRISE AVE STE 113
Mailing Address - Street 2:ADVANCED PHYSICAL THERAPY
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-991-2561
Mailing Address - Fax:920-991-2563
Practice Address - Street 1:2105 E ENTERPRISE AVE # 113
Practice Address - Street 2:ADVANCED PHYSICAL THERAPY
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-991-2561
Practice Address - Fax:920-991-2563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5567490001Medicare NSC
000086443Medicare ID - Type Unspecified