=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730601493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYCARE CLINIC LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2017
-----------------------------------------------------
Last Update Date | 04/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10624 N PORT WASHINGTON RD
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-5049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-497-0003
-----------------------------------------------------
Fax | 920-497-0024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 28900
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54324-0900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-490-9046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CHRIS J AUGUSTIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-965-4065
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------