Healthcare Provider Details

I. General information

NPI: 1134412604
Provider Name (Legal Business Name): BAYCARE CLINIC LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1346 E GREEN BAY ST
SHAWANO WI
54166-2210
US

IV. Provider business mailing address

PO BOX 28900
GREEN BAY WI
54324-0900
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-5555
  • Fax: 920-288-5550
Mailing address:
  • Phone: 920-490-9046
  • Fax: 920-405-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 3
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