Provider Demographics
NPI:1992855084
Name:UROLOGY ASSOCIATES OF GREEN BAY
Entity Type:Organization
Organization Name:UROLOGY ASSOCIATES OF GREEN BAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOEHM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-455-9411
Mailing Address - Street 1:720 S VAN BUREN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3534
Mailing Address - Country:US
Mailing Address - Phone:920-433-9400
Mailing Address - Fax:
Practice Address - Street 1:835 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1282
Practice Address - Country:US
Practice Address - Phone:920-433-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB41406Medicare UPIN
WIH62118Medicare UPIN
WIR06100Medicare UPIN