Provider Demographics
NPI:1306117031
Name:BAYCARE CLINIC LLP
Entity type:Organization
Organization Name:BAYCARE CLINIC LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PROVIDER CREDENTIALING COORD
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HETTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-490-9046
Mailing Address - Street 1:PO BOX 28900
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54324-0900
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:920-405-5384
Practice Address - Street 1:920 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2212
Practice Address - Country:US
Practice Address - Phone:715-524-2001
Practice Address - Fax:715-524-6267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M82740Medicare PIN
WI71460Medicare PIN
WI07650Medicare PIN
MI0N92580Medicare PIN