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General NPI Number Information
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NPI Number | 1508045113
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Entity Type | Organization
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Legal Business Name | APPLETON CARDIAC & THORACIC SURGERY, S.C.
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Dates
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Enumeration Date | 10/31/2007
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Last Update Date | 11/07/2007
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Provider Practice Location Address
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Address Line | 1818 N MEADE ST SUITE N347
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City | APPLETON
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State | WI
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Zip | 54911-3454
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Country | US
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Telephone | 920-225-1449
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Fax | 920-225-1425
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Provider Business Mailing Address
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Address Line | 1818 N MEADE ST SUITE N347
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City | APPLETON
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State | WI
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Zip | 54911-3454
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Country | US
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Telephone | 920-225-1449
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Fax | 920-225-1425
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Authorized Official
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Title or Position | MANAGER
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Name | LYNN KERKHOFF
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Credential |
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Telephone | 920-831-6135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number | 44645
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License Number State | WI
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Legacy Identifiers
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Identifier #1
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Identifier Code | 34279900
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Identifier Type | MEDICAID
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Identifier State | WI
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Identifier Issuer |
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 34279900
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Identifier Type | MEDICAID
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Identifier State | WI
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Identifier Issuer |
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