Provider Demographics
NPI:1043828387
Name:ST MARY'S HOSPITAL MEDICAL CENTER OF GREEN BAY INC.-HOSPITAL SISTERS
Entity Type:Organization
Organization Name:ST MARY'S HOSPITAL MEDICAL CENTER OF GREEN BAY INC.-HOSPITAL SISTERS
Other - Org Name:ST. MARY'S HOSPITAL OUTPATIENT LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-676-1148
Mailing Address - Street 1:1726 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3282
Mailing Address - Country:US
Mailing Address - Phone:920-498-4200
Mailing Address - Fax:
Practice Address - Street 1:1726 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3282
Practice Address - Country:US
Practice Address - Phone:920-498-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST MARY'S HOSPITAL MEDICAL CENTER OF GREEN BAY INC.-HOSPITAL SISTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory