Basic Information
Provider Information | |||||||||
NPI: | 1285908970 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAYCARE CLINIC, LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 28900 | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543240900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204909046 | ||||||||
FaxNumber: | 9204058005 | ||||||||
Practice Location | |||||||||
Address1: | 2401 HOLMGREN WAY | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543045224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204970003 | ||||||||
FaxNumber: | 9204970024 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2012 | ||||||||
LastUpdateDate: | 04/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AUGUSTIAN | ||||||||
AuthorizedOfficialFirstName: | CHRIS | ||||||||
AuthorizedOfficialMiddleName: | JAY | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9204055382 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | C.P.A | ||||||||
NPICertificationDate: | 04/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0014X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 332B00000X |   | WI | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 208100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 1588609648 | 05 | WI |   | MEDICAID |