Healthcare Provider Details

I. General information

NPI: 1174732572
Provider Name (Legal Business Name): BAYCARE CLINIC LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2581 DEVELOPMENT DR
GREEN BAY WI
54311-4247
US

IV. Provider business mailing address

PO BOX 28900
GREEN BAY WI
54324-0900
US

V. Phone/Fax

Practice location:
  • Phone: 920-347-0400
  • Fax: 920-347-0868
Mailing address:
  • Phone: 920-490-9046
  • Fax: 920-405-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRIS JAY AUGUSTINE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: C.P.A.
Phone: 920-405-5382