Healthcare Provider Details

I. General information

NPI: 1861527863
Provider Name (Legal Business Name): EAST SIDE FAMILY PRACTICE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 S MONROE AVE STE 106
GREEN BAY WI
54301-4054
US

IV. Provider business mailing address

424 S MONROE AVE STE 106
GREEN BAY WI
54301-4054
US

V. Phone/Fax

Practice location:
  • Phone: 920-437-4366
  • Fax: 920-437-0954
Mailing address:
  • Phone: 920-437-4366
  • Fax: 920-437-0954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26550
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number26550
License Number StateWI

VIII. Authorized Official

Name: DR. JOSEPH ROBERT DOBSON
Title or Position: PRESIDENT
Credential: D.O.
Phone: 920-437-4366