Healthcare Provider Details

I. General information

NPI: 1336322528
Provider Name (Legal Business Name): BLUE WATER THORACIC AND CARDIOVASCULAR SURGERY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 08/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 STONE ST SUITE 1
PORT HURON MI
48060-3569
US

IV. Provider business mailing address

1107 STONE ST SUITE 1
PORT HURON MI
48060-3569
US

V. Phone/Fax

Practice location:
  • Phone: 810-989-6113
  • Fax: 810-989-6117
Mailing address:
  • Phone: 810-989-6113
  • Fax: 810-989-6117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number5101007542
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number5101007542
License Number StateMI

VIII. Authorized Official

Name: VERNON DENCKLAU
Title or Position: OWNER
Credential: DO
Phone: 810-989-6113