Basic Information
| Provider Information | |||||||||
| NPI: | 1174611313 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ATHLETIC &THERAPEUTIC INSTITUTE OF MILWAUKEE, LLC | ||||||||
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| OtherOrganizationName: | ATHLETIC &THERAPEUTIC INSTITUTE OF GREENFIELD, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4947 PAYSPHERE CIR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606740049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 4861 S 27TH ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532212603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143253325 | ||||||||
| FaxNumber: | 4143253334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 09/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | MCGIVERN | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CCO | ||||||||
| AuthorizedOfficialTelephone: | 6302962222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 41231100 | 05 | WI | MEDICAID | 611826600 | 01 | WI | DEPARTMENT OF LABOR PROVIDER NUMBER | OTHER |