1003388208 NPI number — BAYCARE CLINIC, LLP

Table of content: (NPI 1003388208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003388208 NPI number — BAYCARE CLINIC, LLP

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
BAYCARE CLINIC, LLP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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Provider Other Last Name:
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NPI Number Information

NPI Number:
1003388208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
164 N BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54303-2728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-490-9046
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 W AMERICAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEENAH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54956-1993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-753-9960
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HETTMANN
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
920-490-9046

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)