Provider Demographics
NPI:1982780813
Name:SPORT & SPINE CLINIC OF FORT ATKINSON LIMITED PARTNERSHIP
Entity type:Organization
Organization Name:SPORT & SPINE CLINIC OF FORT ATKINSON LIMITED PARTNERSHIP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP,AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BINSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:713-297-7000
Mailing Address - Street 1:1300 W SAM HOUSTON PKWY S
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-2447
Mailing Address - Country:US
Mailing Address - Phone:713-297-7000
Mailing Address - Fax:713-297-7090
Practice Address - Street 1:222 S WISCONSIN DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549
Practice Address - Country:US
Practice Address - Phone:920-699-4201
Practice Address - Fax:920-699-4204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI526592Medicare Oscar/Certification