Green Lake Medical Clinic , S.C.
Organization Active NPI Family Medicine Physician · Green Lake, WI
NPI 1306986716 · NPPES record last updated Aug 22, 2020
Key facts
- NPI
- 1306986716
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 17659 (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
- Organization subpart
- No
Authorized official
- Name
- Dr. Thomas Rice Willett, D.O.
- Title
- President
- Phone
- (920) 294-3444
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | 17659 | WI | Yes |
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
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 30071600 | Medicaid | WI |
Other providers in Green Lake, WI
- Holley Dornfeld
- Melanie Amanda Ellis
- Nancy Jean Gimenez
- Green Lake County Senior Transportation, Inc
- Green Lake Medical Clinic
- Green Lake School District
- Hagen Chiropractic, LTD.
- Kellie Elizabeth Helmer
- Trina Hernandez
- Amanda M Hetzel
All providers in Green Lake, WI · Family Medicine Physician in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.