Healthcare Provider Details

I. General information

NPI: 1730601493
Provider Name (Legal Business Name): BAYCARE CLINIC LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10624 N PORT WASHINGTON RD
MEQUON WI
53092-5049
US

IV. Provider business mailing address

PO BOX 28900
GREEN BAY WI
54324-0900
US

V. Phone/Fax

Practice location:
  • Phone: 920-497-0003
  • Fax: 920-497-0024
Mailing address:
  • Phone: 920-490-9046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRIS J AUGUSTIAN
Title or Position: CEO
Credential:
Phone: 920-965-4065