Basic Information
| Provider Information | |||||||||
| NPI: | 1043970817 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYCARE CLINIC, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28900 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543240900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204909046 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1110 KEPLER DRIVER | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202885555 | ||||||||
| FaxNumber: | 9202885550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2021 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | HETTMANN | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. PROVIDER CREDENTIALING COORD. | ||||||||
| AuthorizedOfficialTelephone: | 9204909046 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.