Provider Demographics
NPI:1083237754
Name:BAYCARE CLINIC LLP
Entity Type:Organization
Organization Name:BAYCARE CLINIC LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER CREDENTIALING COORDINATOR
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:920-965-4055
Mailing Address - Fax:
Practice Address - Street 1:630 RIVERFRONT DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4615
Practice Address - Country:US
Practice Address - Phone:920-682-6376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty