Basic Information
| Provider Information | |||||||||
| NPI: | 1538581418 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATHLETIC AND THERAPEUTIC INSTITUTE OF MILWAUKEE, LLC | ||||||||
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| OtherOrganizationName: | ATI ACTIVE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2835 N GRANDVIEW BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PEWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530725546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622621100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2014 | ||||||||
| LastUpdateDate: | 01/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | MCGIVERN | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6302962222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.