Healthcare Provider Details

I. General information

NPI: 1396824074
Provider Name (Legal Business Name): CARDIOLOGY ASSOCIATES OF GREEN BAY, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 S. WEBSTER AVE 2ND FLOOR
GREEN BAY WI
54301-3505
US

IV. Provider business mailing address

PO BOX 22425 744 S. WEBSTER AVE
GREEN BAY WI
54305-2425
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-3640
  • Fax: 920-433-3716
Mailing address:
  • Phone: 920-433-3640
  • Fax: 920-433-3716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DEANNE L STAMNES
Title or Position: CREDENTIALING
Credential:
Phone: 920-433-3640