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General NPI Number Information
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NPI Number | 1306986716
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Entity Type | Organization
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Legal Business Name | GREEN LAKE MEDICAL CLINIC , S.C.
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | N6205 BUSSE DRIVE
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City | GREEN LAKE
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State | WI
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Zip | 54941
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Country | US
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Telephone | 920-294-3444
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Fax | 920-294-6660
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Provider Business Mailing Address
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Address Line | N6205 BUSSE DRIVE PO BOX 429
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City | GREEN LAKE
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State | WI
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Zip | 54941
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Country | US
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Telephone | 920-294-3444
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Fax | 920-294-6660
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. THOMAS RICE WILLETT
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Credential | D.O.
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Telephone | 920-294-3444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 17659
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License Number State | WI
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