Provider Demographics
NPI:1649214941
Name:GREEN BAY ONCOLOGY, LTD
Entity Type:Organization
Organization Name:GREEN BAY ONCOLOGY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-965-9526
Mailing Address - Street 1:1726 SHAWANO AVE.
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303
Mailing Address - Country:US
Mailing Address - Phone:920-884-3135
Mailing Address - Fax:920-884-3271
Practice Address - Street 1:1726 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303
Practice Address - Country:US
Practice Address - Phone:920-884-3135
Practice Address - Fax:920-884-3271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32769100Medicaid
O1037OtherRR MEDICARE
MI110B210240OtherBCBS GROUP
0189920001OtherDMERC
WI000007071Medicare PIN
0189920001OtherDMERC
MI110B210240OtherBCBS GROUP