Provider Demographics
NPI:1417313354
Name:AURORA BAY AREA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:AURORA BAY AREA MEDICAL GROUP, LLC
Other - Org Name:AURORA HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:LINEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-288-8612
Mailing Address - Street 1:3100 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-4242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:715-735-1794
Practice Address - Street 1:603 FRENCH ST
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157-1207
Practice Address - Country:US
Practice Address - Phone:715-582-3622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295122729Medicaid