NPIMap

Organization Active NPI

Community Medical Center of Green Lake, LLC

Doing business as CHN Medical Center Green Lake

  • Family Medicine Physician
  • Green Lake, WI
National Provider Identifier
1568622280
Registry record updated May 2, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
44378 Issued in WI
Legal business name
COMMUNITY MEDICAL CENTER OF GREEN LAKE, LLC
Doing business as
CHN Medical Center Green Lake
Practice address
670 County Road a
Green Lake, WI 54941
Phone
(920) 294-0100
Fax
(920) 294-0123
NPI assigned
Jun 16, 2008
Last updated
May 2, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 2, 2014

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

Authorized official

Name
Mr. Thomas Krystowiak
Title
Chief Financial Officer
Phone
(920) 361-1313

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 44378 WI Primary

Addresses

Primary practice location

670 County Road a
Green Lake, WI 54941

Mailing address

670 County Road a
Green Lake, WI 54941
Phone (920) 294-0100

Other names 1

  • CHN Medical Center Green Lake Doing business as

National Provider Directory

National Provider Directory

Member of 2

Organizations this organization is a member of, according to the National Provider Directory.

Locations

225 Memorial Dr
Ste 1300
Berlin, WI 54923
Phone (920) 361-5355

Practitioners & affiliated clinicians

Practitioners 8

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": "1213574400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1398988800000",
    "number": "1568622280",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "670 COUNTY ROAD A",
            "city": "GREEN LAKE",
            "state": "WI",
            "postal_code": "54941",
            "telephone_number": "920-294-0100",
            "fax_number": "920-294-0123"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "670 COUNTY ROAD A",
            "city": "GREEN LAKE",
            "state": "WI",
            "postal_code": "54941",
            "telephone_number": "920-294-0100",
            "fax_number": "920-294-0123"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY MEDICAL CENTER OF GREEN LAKE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-06-16",
        "last_updated": "2014-05-02",
        "status": "A",
        "authorized_official_last_name": "KRYSTOWIAK",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "920-361-1313",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "44378",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CHN Medical Center Green Lake",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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 May 2, 2014; 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.