Provider Demographics
NPI:1811004872
Name:BAY AREA MEDICAL CENTER INC
Entity Type:Organization
Organization Name:BAY AREA MEDICAL CENTER INC
Other - Org Name:BAY AREA OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:TACCOLINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-735-6621
Mailing Address - Street 1:3100 SHORE DR-
Mailing Address - Street 2:SUITE COS
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-4242
Mailing Address - Country:US
Mailing Address - Phone:715-735-8072
Mailing Address - Fax:715-735-8011
Practice Address - Street 1:3100 SHORE DR-
Practice Address - Street 2:SUITE COS
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4242
Practice Address - Country:US
Practice Address - Phone:715-735-8072
Practice Address - Fax:715-735-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8044-0423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33058800Medicaid
WI0526520001Medicare NSC