Basic Information
| Provider Information | |||||||||
| NPI: | 1366424111 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREEN BAY EMERGENCY MEDICINE SERVICES S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 INDUSTRIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | GREENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531292452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144234100 | ||||||||
| FaxNumber: | 4144234134 | ||||||||
| Practice Location | |||||||||
| Address1: | 744 S WEBSTER AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204333500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANO | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9204333500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 21289100 | 05 | WI | MEDICAID |