Provider Demographics
NPI:1164411997
Name:SPORTS MEDICINE & ORTHOPEDIC CENTER, S.C.
Entity type:Organization
Organization Name:SPORTS MEDICINE & ORTHOPEDIC CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:B
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:3033 W LAYTON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2628
Mailing Address - Country:US
Mailing Address - Phone:414-647-0033
Mailing Address - Fax:414-647-0079
Practice Address - Street 1:3033 W LAYTON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2628
Practice Address - Country:US
Practice Address - Phone:414-647-0033
Practice Address - Fax:414-647-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32685200Medicaid
WI000001621Medicare PIN
WI0837380001Medicare NSC