Provider Demographics
NPI:1952420382
Name:GREEN BAY PLASTIC SURGICAL ASSOC
Entity Type:Organization
Organization Name:GREEN BAY PLASTIC SURGICAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLZEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-432-7000
Mailing Address - Street 1:704 S WEBSTER AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3528
Mailing Address - Country:US
Mailing Address - Phone:920-432-7000
Mailing Address - Fax:920-436-8251
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-432-7000
Practice Address - Fax:920-436-8251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty