Provider Demographics
NPI:1568622280
Name:COMMUNITY MEDICAL CENTER OF GREEN LAKE, LLC
Entity Type:Organization
Organization Name:COMMUNITY MEDICAL CENTER OF GREEN LAKE, LLC
Other - Org Name:CHN MEDICAL CENTER GREEN LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KRYSTOWIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-361-1313
Mailing Address - Street 1:670 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941
Mailing Address - Country:US
Mailing Address - Phone:920-294-0100
Mailing Address - Fax:920-294-0123
Practice Address - Street 1:670 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941
Practice Address - Country:US
Practice Address - Phone:920-294-0100
Practice Address - Fax:920-294-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21329400Medicaid
WIWI1031Medicare PIN
WI6526320001Medicare NSC