Basic Information
| Provider Information | |||||||||
| NPI: | 1659436368 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATHLETIC AND THERAPEUTIC INSTITUTE OF MILWAUKEE, LLC | ||||||||
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| OtherOrganizationName: | ATHLETIC AND THERAPEUTIC INSTITUTE OF NEW BERLIN, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4947 PAYSHERE CIRCLE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606744064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
| FaxNumber: | 6307596106 | ||||||||
| Practice Location | |||||||||
| Address1: | 15312 W BELOIT ROAD | ||||||||
| Address2: | |||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626415771 | ||||||||
| FaxNumber: | 2626416317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 03/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | BOGOVICH | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6302962222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 41231600 | 05 | WI | MEDICAID | 611826603 | 01 | WI | DEPARTMENT OF LABOR PROVIDER NUMBER | OTHER |