Provider Demographics
| NPI: | 1588609648 |
|---|---|
| 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: | AUGUSTIAN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | CPA |
| Authorized Official - Phone: | 920-490-9046 |
| 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: | 2845 GREENBRIER RD |
| Practice Address - Street 2: | |
| Practice Address - City: | GREEN BAY |
| Practice Address - State: | WI |
| Practice Address - Zip Code: | 54311-6519 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 920-288-8000 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-06-20 |
| Last Update Date: | 2022-03-31 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
| No | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | Group - Multi-Specialty |
| No | 204E00000X | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | Group - Multi-Specialty | |
| No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
| No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | Group - Multi-Specialty |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
| No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
| No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
| No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MI | 14-0-B1-1013-0 | Other | BCBSM |
| WI | 32874000 | Medicaid | |
| MI | 34-0-B1-1010 | Other | BCBSM |
| MI | CI3978 | Other | RAILROAD |
| MI | 4082659 | Medicaid | |
| WI | CI3977 | Other | RAILROAD |
| MI | 34-0-B1-1010 | Other | BCBSM |
| WI | =========034 | Other | BCBS ANTHEM |
| WI | =========034 | Other | BCBS ANTHEM |
| WI | 71460 | Medicare ID - Type Unspecified | |
| MI | 4082659 | Medicaid | |
| MI | 14-0-B1-1013-0 | Other | BCBSM |
| MI | CI3978 | Other | RAILROAD |
