Healthcare Provider Details

I. General information

NPI: 1154400034
Provider Name (Legal Business Name): OB-GYN ASSOC OF GREEN BAY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 S WEBSTER AVE STE 300
GREEN BAY WI
54301
US

IV. Provider business mailing address

1350 WITTMANN DRIVE HEALTHCARE MANAGEMENT CONSULTANTS
MENASHA WI
54952-3809
US

V. Phone/Fax

Practice location:
  • Phone: 920-468-3443
  • Fax: 920-432-6313
Mailing address:
  • Phone: 920-886-6565
  • Fax: 920-886-6570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VC0200X
TaxonomyCritical Care Medicine (Obstetrics & Gynecology) Physician
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number
License Number StateWI

VIII. Authorized Official

Name: ROBERT KNOX DEMOTT
Title or Position: OWNER OPERATOR
Credential: MD
Phone: 920-468-3443