MEDICARE: SOUTHPORT CARDIOVASCULAR SURGEONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	38886	WI

General Provider Information

NPI Number	:	1063894723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHPORT CARDIOVASCULAR SURGEONS LLC

Provider Business Mailing Address
First Line	:	7137 236TH AVENUE
Second Line	:	#103
City	:	PADDOCK LAKE
State	:	WI
Zip	:	53168
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7137 236TH AVENUE
Second Line	:	#103
City	:	PADDOCK LAKE
State	:	WI
Zip	:	53168
Country	:	US
Telephone Number	:	262-843-4422
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHRISTOPHER STONE
Credential	:	MD
Telephone Number	:	262-843-4422

Provider Enumeration Date	:	06/18/2015
Last Update Date	:	06/18/2015

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