Healthcare Provider Details

I. General information

NPI: 1558534313
Provider Name (Legal Business Name): NEW MOM'S OF GREEN BAY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 S WEBSTER AVE STOP 110
GREEN BAY WI
54301-3528
US

IV. Provider business mailing address

704 S WEBSTER AVE STOP 110
GREEN BAY WI
54301-3528
US

V. Phone/Fax

Practice location:
  • Phone: 920-431-0200
  • Fax: 920-431-0300
Mailing address:
  • Phone: 920-431-0200
  • Fax: 920-431-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number44616020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number44616020
License Number StateWI

VIII. Authorized Official

Name: ALLAHYAR JAZAYERI
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 920-338-6868