Healthcare Provider Details

I. General information

NPI: 1548264336
Provider Name (Legal Business Name): PAUL MICHAEL STOVER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2806 RIVERVIEW DR
GREEN BAY WI
54313-6717
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 920-498-7546
  • Fax: 920-569-4129
Mailing address:
  • Phone: 920-683-5278
  • Fax: 920-686-9674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number38944-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: