Healthcare Provider Details

I. General information

NPI: 1134490758
Provider Name (Legal Business Name): BAYCARE CLINIC LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 MARITIME DR
MANITOWOC WI
54220-2961
US

IV. Provider business mailing address

PO BOX 28900
GREEN BAY WI
54324-0900
US

V. Phone/Fax

Practice location:
  • Phone: 920-682-9121
  • Fax: 920-682-7188
Mailing address:
  • Phone: 920-490-9046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: TAYLOR KONKLE
Title or Position: PAYOR ENROLLMENT
Credential:
Phone: 920-301-1327