NPIMap

Organization Active NPI

Space Coast Family Practice

  • Clinic/Center
  • Green Bay, WI
National Provider Identifier
1811099054
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
License
ME88311 Issued in FL
Legal business name
SPACE COAST FAMILY PRACTICE
Practice address
3067 Windland Dr
Green Bay, WI 54311-7574
Phone
(920) 544-5868
NPI assigned
Sep 1, 2006
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 Charles Betka, MDNPI 1164454302
Title
President
Phone
(920) 544-5868

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X ME88311 FL Primary

Addresses

Primary practice location

3067 Windland Dr
Green Bay, WI 54311-7574

Mailing address

3067 Windland Dr
Green Bay, WI 54311-7574
Phone (920) 544-5868

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": "1157068800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1811099054",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3067 WINDLAND DR",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543117574",
            "telephone_number": "920-544-5868"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3067 WINDLAND DR",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543117574",
            "telephone_number": "920-544-5868"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPACE COAST FAMILY PRACTICE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-01",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BETKA",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_middle_name": "CHARLES",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "920-544-5868",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "FL",
            "license": "ME88311",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Green Bay, 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.