MEDICARE: BAYCARE CLINIC LLP

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1417992959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYCARE CLINIC LLP

Provider Business Mailing Address
First Line	:	PO BOX 28900
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54324-0900
Country	:	US
Telephone Number	:	920-490-9046
Fax Number	:	920-405-5388

Provider Business Practice Location Address
First Line	:	3130 SHORE DR
Second Line	:	STE 109
City	:	MARINETTE
State	:	WI
Zip	:	54143-4291
Country	:	US
Telephone Number	:	715-735-9494
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. CHRIS JAY AUGUSTIAN
Credential	:	CPA
Telephone Number	:	920-405-5382

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	04/13/2022

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