MEDICARE: NORTHREACH HEALTHCARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1205973575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHREACH HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 22487
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54305-2487
Country	:	US
Telephone Number	:	920-445-7226
Fax Number	:	920-445-7229

Provider Business Practice Location Address
First Line	:	2935 SHORE DR
Second Line	:
City	:	MARINETTE
State	:	WI
Zip	:	54143-4237
Country	:	US
Telephone Number	:	715-732-9193
Fax Number	:	715-732-9196

Authorized Official
Title or Position	:	DIRECTOR OF BUSINESS SERVICES
Name	:	CAROL HIPKE
Credential	:
Telephone Number	:	715-732-2075

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	03/14/2017

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