Provider Demographics
NPI:1154400034
Name:OB-GYN ASSOC OF GREEN BAY LTD
Entity type:Organization
Organization Name:OB-GYN ASSOC OF GREEN BAY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KNOX
Authorized Official - Last Name:DEMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-468-3443
Mailing Address - Street 1:1350 WITTMANN DRIVE
Mailing Address - Street 2:HEALTHCARE MANAGEMENT CONSULTANTS
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-3809
Mailing Address - Country:US
Mailing Address - Phone:920-886-6565
Mailing Address - Fax:920-886-6570
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:STE 300
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-468-3443
Practice Address - Fax:920-432-6313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207VC0200X, 364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VC0200XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyCritical Care MedicineGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32400300Medicaid
WI41963900Medicaid
WI30661000Medicaid
WI30984300Medicaid
WI41964300Medicaid
WI43977500Medicaid
1174547244OtherKIM SHEFCHIK PAC NPI
WI32400300Medicaid
WI41963900Medicaid
WI30984300Medicaid
P73555Medicare UPIN
P73676Medicare UPIN
1174547244OtherKIM SHEFCHIK PAC NPI
P73556Medicare UPIN