Community Medical Center of Green Lake, LLC
Organization Active NPI Family Medicine Physician · Green Lake, WI
NPI 1568622280 · NPPES record last updated May 2, 2014
Key facts
- NPI
- 1568622280
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 44378 (WI)
- Legal business name
- COMMUNITY MEDICAL CENTER OF GREEN LAKE, LLC
- Practice address
- 670 County Road a
Green Lake, WI 54941 - Phone
- (920) 294-0100
- Fax
- (920) 294-0123
- NPI assigned
- Jun 16, 2008
- Organization subpart
- No
Authorized official
- Name
- Mr. Thomas Krystowiak
- Title
- Chief Financial Officer
- Phone
- (920) 361-1313
Member of 2
Practitioners 8
-
Jeffrey Carroll, MD
-
Colleen K Micele, FNP
-
Anthony J. Racki, MD
-
Thomas Rice Willett, D.O.
-
Basharat A. Shah, MD
National Provider Directory
Locations
225 Memorial Dr
Ste 1300
Berlin, WI 54923
Phone (920) 361-5355
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | 44378 | WI | Yes |
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 identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 21329400 | Medicaid | WI |
Other names
- CHN Medical Center Green Lake
Other providers in Green Lake, WI
- Active Family Chiropractic Center LLC
- Jessica A. Bowman
- Kevin Daniel Castleberry
- Chiroplus Complimentary Health Care Center LLC
- Community Options, Inc.
- County of Green Lake
- County of Green Lake
- Shirley J. Dawson
- Holley Dornfeld
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 May 2, 2014. 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.