Medical School Information |
|
Medical School Name
|
OTHER
|
|
Individual professional's medical school
|
|
Graduation Year
|
1984
|
|
Individual professional's medical school graduation year
|
|
Primary Specialty
|
PHYSICAL MEDICINE AND REHABILITATION
|
|
Primary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 1
|
PAIN MANAGEMENT
|
|
First secondary medical specialty reported by the individual professional in the selected enrollment
|
|
All Secondary Specialties
|
PAIN MANAGEMENT
|
|
All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas
|
Practice Information |
|
Organization Legal Name
|
BAYCARE CLINIC LLP
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
4385554328
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
167
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
501 N 10TH ST
|
|
Group Practice or individual's line 1 address
|
|
City
|
MANITOWOC
|
|
Group Practice or individual's city
|
|
State
|
WI
|
|
Group Practice or individual's state
|
|
Zip Code
|
542204039
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
9206826376
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
520193
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
AURORA BAYCARE MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
520034
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
AURORA MEDICAL CTR MANITOWOC COUNTY
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Hospital Affiliation CCN 3
|
520113
|
|
Medicare CCN of hospital where individual professional provides service 3
|
|
Hospital Affiliation LBN 3
|
BAY AREA MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 3
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|