Provider Demographics
NPI:1649246877
Name:ST MARY'S HOSPITAL MEDICAL CENTER OF GREEN BAY INC.-HOSPITAL SISTERS
Entity type:Organization
Organization Name:ST MARY'S HOSPITAL MEDICAL CENTER OF GREEN BAY INC.-HOSPITAL SISTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-676-1148
Mailing Address - Street 1:1726 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3282
Mailing Address - Country:US
Mailing Address - Phone:920-498-4200
Mailing Address - Fax:
Practice Address - Street 1:1726 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3216
Practice Address - Country:US
Practice Address - Phone:920-498-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICD2700OtherRAILROAD MEDICARE
WI11013800Medicaid
WI000021141Medicare ID - Type Unspecified
WI0687670001Medicare NSC
WI11013800Medicaid
WI520097Medicare ID - Type Unspecified