Provider Demographics
NPI:1336412634
Name:BAYCARE CLINIC, LLP
Entity type:Organization
Organization Name:BAYCARE CLINIC, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:AUGUSTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:920-405-5382
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:920-405-8005
Practice Address - Street 1:725 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3500
Practice Address - Country:US
Practice Address - Phone:920-288-8350
Practice Address - Fax:920-288-8355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1588609648Medicaid
WI07650Medicare PIN
WI71460Medicare PIN