Provider Demographics
NPI:1770660805
Name:BAY AREA MEDICAL CENTER INC
Entity Type:Organization
Organization Name:BAY AREA MEDICAL CENTER INC
Other - Org Name:BAY AREA MEDICAL CENTER INC PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:DANIAL
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:715-735-8016
Mailing Address - Street 1:3100 SHORE DRIVE
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:715-735-4200
Mailing Address - Fax:715-735-1791
Practice Address - Street 1:3100 SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4242
Practice Address - Country:US
Practice Address - Phone:715-735-4200
Practice Address - Fax:715-735-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6698333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1711544Medicaid
MI1711526Medicaid
WI11001400Medicaid
WI520113Medicare Oscar/Certification