NPIMap

Organization Active NPI

Green Lake Medical Clinic , S.C.

  • Family Medicine Physician
  • Green Lake, WI
National Provider Identifier
1306986716
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
17659 Issued in WI
Legal business name
GREEN LAKE MEDICAL CLINIC , S.C.
Practice address
N6205 Busse Drive
Green Lake, WI 54941
Phone
(920) 294-3444
Fax
(920) 294-6660
NPI assigned
Feb 7, 2007
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Thomas Rice Willett, D.O.NPI 1902806243
Title
President
Phone
(920) 294-3444

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 17659 WI Primary

Addresses

Primary practice location

N6205 Busse Drive
Green Lake, WI 54941

Mailing address

N6205 Busse Drive
PO Box 429
Green Lake, WI 54941
Phone (920) 294-3444

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170806400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1306986716",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "N6205 BUSSE DRIVE",
            "address_2": "PO BOX 429",
            "city": "GREEN LAKE",
            "state": "WI",
            "postal_code": "54941",
            "telephone_number": "920-294-3444",
            "fax_number": "920-294-6660"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "N6205 BUSSE DRIVE",
            "city": "GREEN LAKE",
            "state": "WI",
            "postal_code": "54941",
            "telephone_number": "920-294-3444",
            "fax_number": "920-294-6660"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREEN LAKE MEDICAL CLINIC , S.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-07",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WILLETT",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_middle_name": "RICE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "920-294-3444",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "17659",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Green Lake, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.