Provider Demographics
NPI:1104131960
Name:GREEN BAY ROAD MEDICAL SERVICES INC
Entity type:Organization
Organization Name:GREEN BAY ROAD MEDICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MATTEUCCI
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:262-653-9221
Mailing Address - Street 1:6127 GREEN BAY ROAD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2930
Mailing Address - Country:US
Mailing Address - Phone:262-653-9221
Mailing Address - Fax:262-653-9229
Practice Address - Street 1:6127 GREEN BAY ROAD
Practice Address - Street 2:SUITE 600
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2930
Practice Address - Country:US
Practice Address - Phone:262-653-9221
Practice Address - Fax:262-653-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical