Healthcare Provider Details

I. General information

NPI: 1932671138
Provider Name (Legal Business Name): BAYCARE CLINIC, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 ELLIS ST
KEWAUNEE WI
54216-1825
US

IV. Provider business mailing address

PO BOX 28900
GREEN BAY WI
54324-0900
US

V. Phone/Fax

Practice location:
  • Phone: 877-462-9465
  • Fax:
Mailing address:
  • Phone: 920-490-9046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE HETTMANN
Title or Position: PROVIDER CREDENTIALING COORDINATOR
Credential:
Phone: 920-490-9046