Provider Demographics
NPI:1447477245
Name:BLUEMOUND ORTHOPAEDIC GROUP, LTD
Entity type:Organization
Organization Name:BLUEMOUND ORTHOPAEDIC GROUP, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-786-2875
Mailing Address - Street 1:13255 W BLUEMOUND RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6245
Mailing Address - Country:US
Mailing Address - Phone:262-786-2875
Mailing Address - Fax:262-786-2096
Practice Address - Street 1:13255 W BLUEMOUND RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6245
Practice Address - Country:US
Practice Address - Phone:262-786-2875
Practice Address - Fax:262-786-2096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0862990001Medicare NSC