Provider Demographics
NPI:1558306332
Name:EVOLUTION EXERCISE & SPINE CENTER
Entity type:Organization
Organization Name:EVOLUTION EXERCISE & SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIEBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-896-6967
Mailing Address - Street 1:N22W27847 EDGEWATER DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-5227
Mailing Address - Country:US
Mailing Address - Phone:262-264-0080
Mailing Address - Fax:262-264-0081
Practice Address - Street 1:N22 W27847 EDGEWATER DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5402
Practice Address - Country:US
Practice Address - Phone:262-264-0080
Practice Address - Fax:262-264-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========014OtherBLUE CROSS
=========014OtherBLUE CROSS
WI81054Medicare ID - Type Unspecified