Provider Demographics
NPI:1699778829
Name:CHIPPEWA VALLEY ORTHOPEDICS AND SPORTS MEDICINE CLINIC SC
Entity type:Organization
Organization Name:CHIPPEWA VALLEY ORTHOPEDICS AND SPORTS MEDICINE CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:CROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-832-1400
Mailing Address - Street 1:1200 OAKLEAF WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-2245
Mailing Address - Country:US
Mailing Address - Phone:715-832-1400
Mailing Address - Fax:715-832-4187
Practice Address - Street 1:1200 OAKLEAF WAY
Practice Address - Street 2:SUITE A
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-2245
Practice Address - Country:US
Practice Address - Phone:715-832-1400
Practice Address - Fax:715-832-4187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207T00000X, 207X00000X, 213ES0103X, 261QM1200X, 261QP2000X, 363A00000X
WI54216208VP0014X
WI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100272795Medicaid
WI21278700Medicaid
WI2416091OtherUNITED HEALTHCARE
WI=========OtherBLUE CROSS BLUE SHIELD
WI100249466Medicaid
WI542R9CHOtherBCBS OF MN
WI41741700Medicaid
WI220399400OtherOWCP
WI41741700Medicaid
WI5158140001Medicare NSC