Provider Demographics
NPI:1558534313
Name:NEW MOM'S OF GREEN BAY SC
Entity Type:Organization
Organization Name:NEW MOM'S OF GREEN BAY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLAHYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:JAZAYERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-338-6868
Mailing Address - Street 1:704 S WEBSTER AVE STOP 110
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3528
Mailing Address - Country:US
Mailing Address - Phone:920-431-0200
Mailing Address - Fax:920-431-0300
Practice Address - Street 1:704 S WEBSTER AVE STOP 110
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-431-0200
Practice Address - Fax:920-431-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44616020207VM0101X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty