MEDICARE: CHANDLER STOCKWELL

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	242T00000X	Perfusionist

General Provider Information

NPI Number	:	1356989800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANDLER STOCKWELL

Provider Business Mailing Address
First Line	:	45211 HELM ST
Second Line	:
City	:	PLYMOUTH
State	:	MI
Zip	:	48170-6023
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5016 NORTH HIGHWAY 75
Second Line	:
City	:	DENISON
State	:	TX
Zip	:	75020
Country	:	US
Telephone Number	:	903-416-4000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2019
Last Update Date	:	12/16/2019

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Directions to “ CHANDLER STOCKWELL ” Practice Location

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