1659645380 NPI number — BAYCARE CLINIC, LLP

Table of content: (NPI 1659645380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659645380 NPI number — BAYCARE CLINIC, LLP

Organization/Personal Information

Employer Identification Number (EIN):
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:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659645380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 28900
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:
54324-0900
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:
30 N 18TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STURGEON BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54235-3207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-743-9532
Provider Business Practice Location Address Fax Number:
920-743-9538
Provider Enumeration Date:
02/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
AUGUSTIAN
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
920-405-5382

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1588609648 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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