Healthcare Provider Details

I. General information

NPI: 1033867213
Provider Name (Legal Business Name): BAYCARE CLINIC, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 MEMORIAL DR
TWO RIVERS WI
54241-3923
US

IV. Provider business mailing address

PO BOX 28900
GREEN BAY WI
54324-0900
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8000
  • Fax:
Mailing address:
  • Phone: 920-490-9046
  • Fax: 920-405-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE HETTMANN
Title or Position: SR PROVIDER CREDENTIALING COORD.
Credential: CPCS
Phone: 920-965-4055