Provider Demographics
NPI:1306816574
Name:GREEN BAY HEARTCARE S.C.
Entity Type:Organization
Organization Name:GREEN BAY HEARTCARE S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:FERGUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-496-8877
Mailing Address - Street 1:1727 SHAWANO AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3268
Mailing Address - Country:US
Mailing Address - Phone:920-496-8877
Mailing Address - Fax:920-496-3061
Practice Address - Street 1:1727 SHAWANO AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3268
Practice Address - Country:US
Practice Address - Phone:920-496-8877
Practice Address - Fax:920-496-3061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32864300Medicaid
WI32864300Medicaid