Provider Demographics
NPI:1316039068
Name:GREEN BAY PODIATRY ASSOCIATES SC
Entity Type:Organization
Organization Name:GREEN BAY PODIATRY ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:NORBERT
Authorized Official - Last Name:TILKENS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-498-0110
Mailing Address - Street 1:2036 S RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4127
Mailing Address - Country:US
Mailing Address - Phone:920-498-0110
Mailing Address - Fax:920-498-3481
Practice Address - Street 1:2036 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-4127
Practice Address - Country:US
Practice Address - Phone:920-498-0110
Practice Address - Fax:920-498-3481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI353-025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI82358Medicare ID - Type Unspecified
0634820001Medicare NSC