=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649214941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN BAY ONCOLOGY, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2006
-----------------------------------------------------
Last Update Date | 10/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1726 SHAWANO AVE
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-884-3135
-----------------------------------------------------
Fax | 920-884-3271
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1726 SHAWANO AVE.
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-884-3135
-----------------------------------------------------
Fax | 920-884-3271
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MS. GINA M MOON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-965-9526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------