Provider Demographics
NPI:1538356985
Name:GREEN BAY CHEST AND INFECTIOUS DISEASES SC
Entity type:Organization
Organization Name:GREEN BAY CHEST AND INFECTIOUS DISEASES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-433-7516
Mailing Address - Street 1:704 S WEBSTER AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3528
Mailing Address - Country:US
Mailing Address - Phone:920-433-7516
Mailing Address - Fax:920-433-7464
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-7516
Practice Address - Fax:920-433-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30054207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty