Healthcare Provider Details

I. General information

NPI: 1568622280
Provider Name (Legal Business Name): COMMUNITY MEDICAL CENTER OF GREEN LAKE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 COUNTY ROAD A
GREEN LAKE WI
54941
US

IV. Provider business mailing address

670 COUNTY ROAD A
GREEN LAKE WI
54941
US

V. Phone/Fax

Practice location:
  • Phone: 920-294-0100
  • Fax: 920-294-0123
Mailing address:
  • Phone: 920-294-0100
  • Fax: 920-294-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number44378
License Number StateWI

VIII. Authorized Official

Name: MR. THOMAS KRYSTOWIAK
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 920-361-1313