NPIMap

Organization Active NPI

Sport Clinic of Greater Milwaukee

  • Physical Therapist
  • Wauwatosa, WI
National Provider Identifier
1275628208
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
SPORT CLINIC OF GREATER MILWAUKEE
Practice address
11904 W North Ave
Ste 100
Wauwatosa, WI 53226-2062
Phone
(414) 453-8616
Fax
(414) 453-6150
NPI assigned
Oct 4, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Matthew Becker
Title
C.F.O.
Phone
(414) 453-8616

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical TherapistGroup: 193400000X SINGLE SPECIALTY GROUP 225100000X Primary

Addresses

Primary practice location

11904 W North Ave
Ste 100
Wauwatosa, WI 53226-2062

Mailing address

11904 W North Ave
Ste 100
Wauwatosa, WI 53226-2062
Phone (414) 453-8616

Other identifiers 1

IdentifierTypeStateIssuer
40418200MedicaidWI

National Provider Directory

National Provider Directory

Locations

707 W Glencoe Pl
Bayside, WI 53217
Phone (414) 351-5794

11904 W North Ave
Wauwatosa, WI 53226
Phone (414) 206-3356

11904 W North Ave
Ste 100
Wauwatosa, WI 53226
Phone (414) 453-8616

Practitioners & affiliated clinicians

Practitioners 20

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 20

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159920000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1275628208",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11904 W NORTH AVE",
            "address_2": "STE 100",
            "city": "WAUWATOSA",
            "state": "WI",
            "postal_code": "532262062",
            "telephone_number": "414-453-8616",
            "fax_number": "414-453-6150"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11904 W NORTH AVE",
            "address_2": "STE 100",
            "city": "WAUWATOSA",
            "state": "WI",
            "postal_code": "532262062",
            "telephone_number": "414-453-8616",
            "fax_number": "414-453-6150"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPORT CLINIC OF GREATER MILWAUKEE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-04",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BECKER",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_title_or_position": "C.F.O.",
        "authorized_official_telephone_number": "414-453-8616",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "40418200",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Wauwatosa, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.