Basic Information
| Provider Information | |||||||||
| NPI: | 1033867213 | ||||||||
| 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 | ||||||||
| FaxNumber: | 9204055388 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | TWO RIVERS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542413923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2022 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | HETTMANN | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR PROVIDER CREDENTIALING COORD. | ||||||||
| AuthorizedOfficialTelephone: | 9209654055 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPCS | ||||||||
| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.