MEDICARE: PYRAMID PSYCHIATRIC CARE, 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	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1295226512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PYRAMID PSYCHIATRIC CARE, LLC

Provider Business Mailing Address
First Line	:	2475 UNIVERSITY AVE STE A
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54302-5099
Country	:	US
Telephone Number	:	920-632-2248
Fax Number	:	920-351-4826

Provider Business Practice Location Address
First Line	:	2475 UNIVERSITY AVE STE A
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54302-5099
Country	:	US
Telephone Number	:	920-632-2248
Fax Number	:	920-351-4826

Authorized Official
Title or Position	:	FACILITY DIRECTOR
Name	:	ANDREW TODD BROCKER
Credential	:
Telephone Number	:	920-632-2248

Provider Enumeration Date	:	05/22/2018
Last Update Date	:	05/22/2018

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