Provider Demographics
NPI:1174732572
Name:BAYCARE CLINIC LLP
Entity type:Organization
Organization Name:BAYCARE CLINIC LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:AUGUSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:920-405-5382
Mailing Address - Street 1:PO BOX 28900
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54324-0900
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:920-405-5388
Practice Address - Street 1:2581 DEVELOPMENT DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4247
Practice Address - Country:US
Practice Address - Phone:920-347-0400
Practice Address - Fax:920-347-0868
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAYCARE CLINIC LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1280110013Medicare NSC