NPIMap

Organization Active NPI

Sport Clinic Physical Therapy Inc

  • Physical Therapist
  • Bayside, WI
National Provider Identifier
1912918475
Registry record updated Jun 12, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
SPORT CLINIC PHYSICAL THERAPY INC
Practice address
8911 N Port Washington Rd
Sport Clinic Physical Therapy Inc
Bayside, WI 53217-1634
Phone
(414) 351-5794
Fax
(414) 351-2770
NPI assigned
Aug 10, 2006
Last updated
Jun 12, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2012

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

Authorized official

Name
John A Hendrickson, PTNPI 1700897279
Title
Ower President
Phone
(414) 351-5794

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X NU Primary

Addresses

Primary practice location

8911 N Port Washington Rd
Sport Clinic Physical Therapy Inc
Bayside, WI 53217-1634

Mailing address

8911 N Port Washington Rd
Sport Clinic Physical Therapy Inc
Bayside, WI 53217-1634
Phone (414) 351-5794

Other identifiers 1

IdentifierTypeStateIssuer
40424700MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050314000970 WI Part B Supplier - Physical/Occupational Therapy Group in Private Practice 0244285187 Receives reassigned benefits from 18 practitioners
Practice locations: Cedarburg, WI; Mequon, WI

National Provider Directory

National Provider Directory

Locations

8911 N Port Washington Rd
Bayside, WI 53217
Phone (414) 305-7206

7269 State Road 60
Cedarburg, WI 53012
Phone (262) 377-8350

N72W13400 Lund Ln
Menomonee Falls, WI 53051
Phone (262) 208-1344

10620 N Port Washington Rd
Ste 202
Mequon, WI 53092
Phone (414) 351-5794

Practitioners & affiliated clinicians

Practitioners 29

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 29

NPI Registry JSON

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

{
    "created_epoch": "1155168000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1339459200000",
    "number": "1912918475",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8911 N PORT WASHINGTON RD",
            "address_2": "SPORT CLINIC PHYSICAL THERAPY INC",
            "city": "BAYSIDE",
            "state": "WI",
            "postal_code": "532171634",
            "telephone_number": "414-351-5794",
            "fax_number": "414-351-2770"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8911 N PORT WASHINGTON RD",
            "address_2": "SPORT CLINIC PHYSICAL THERAPY INC",
            "city": "BAYSIDE",
            "state": "WI",
            "postal_code": "532171634",
            "telephone_number": "414-351-5794",
            "fax_number": "414-351-2770"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPORT CLINIC PHYSICAL THERAPY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-10",
        "last_updated": "2012-06-12",
        "status": "A",
        "authorized_official_last_name": "HENDRICKSON",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWER PRESIDENT",
        "authorized_official_telephone_number": "414-351-5794",
        "authorized_official_credential": "PT"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "40424700",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Bayside, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.