MEDICARE: PAUL T. STOCKMANN M.D.

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	2086S0120X	Pediatric Surgery Physician	057466	MI
2	2086S0120X	Pediatric Surgery Physician	01078636A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	PS057466	OTHER		CHAMPUS-CHAMPUS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	020H277290	OTHER	MI	BLUE CROSS BLUE SHIELD MI
6	PS057466	OTHER		COMMERCIAL-COMMERCIAL NUMBER
7	1396817714	OTHER	MI	GROUP NPI
8	700H262310	OTHER		BLUE CROSS-BLUE CROSS

General Provider Information

NPI Number	:	1588664932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL T. STOCKMANN M.D.

Provider Business Mailing Address
First Line	:	CHILDRENS HOSPITAL OF MICHIGAN
Second Line	:	3901 BEAUBIEN BLVD
City	:	DETROIT
State	:	MI
Zip	:	48201
Country	:	US
Telephone Number	:	313-831-3220
Fax Number	:

Provider Business Practice Location Address
First Line	:	11123 PARKVIEW PLAZA DR STE 200
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1707
Country	:	US
Telephone Number	:	260-425-6100
Fax Number	:	260-425-6105

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	04/23/2018

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