Organization
GREEN LAKE MEDICAL CLINIC , S.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. THOMAS RICE WILLETT D.O. (PRESIDENT)
(920) 294-3444
Entity
Organization
Contact information
Practice address
N6205 BUSSE DRIVE, GREEN LAKE, WI 54941
(920) 294-3444
(920) 294-6660
Mailing address
N6205 BUSSE DRIVE, PO BOX 429, GREEN LAKE, WI 54941
(920) 294-3444
(920) 294-6660
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
17659
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
30071600
—
WI
Enumeration date
02/07/2007
Last updated
08/22/2020
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