Provider Demographics
NPI:1871583203
Name:ENDOCRINOLOGY ASSOCIATES OF GREEN BAY SC
Entity type:Organization
Organization Name:ENDOCRINOLOGY ASSOCIATES OF GREEN BAY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KASDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-468-9588
Mailing Address - Street 1:1901 S WEBSTER AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2281
Mailing Address - Country:US
Mailing Address - Phone:920-468-9588
Mailing Address - Fax:920-468-1342
Practice Address - Street 1:1901 S WEBSTER AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2281
Practice Address - Country:US
Practice Address - Phone:920-468-9588
Practice Address - Fax:920-468-1342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32781100Medicaid
WI000007560Medicare ID - Type Unspecified