CARDIOLOGY ASSOCIATES OF GREEN BAY, LTD

Provider Demographics

• NPI: 1396824074
• Name: CARDIOLOGY ASSOCIATES OF GREEN BAY, LTD
• Entity Type: Organization
• Organization Name: CARDIOLOGY ASSOCIATES OF GREEN BAY, LTD
• Authorized Official - Title/Position: CREDENTIALING
• Authorized Official - First Name: DEANNE
• Authorized Official - Middle Name: L
• Authorized Official - Last Name: STAMNES
• Authorized Official - Phone: 920-433-3640
• Mailing Address - Street 1: PO BOX 22425
• Mailing Address - Street 2: 744 S. WEBSTER AVE
• Mailing Address - City: GREEN BAY
• Mailing Address - State: WI
• Mailing Address - Zip Code: 54305-2425
• Mailing Address - Country: US
• Mailing Address - Phone: 920-433-3640
• Mailing Address - Fax: 920-433-3716
• Practice Address - Street 1: 744 S. WEBSTER AVE
• Practice Address - Street 2: 2ND FLOOR
• Practice Address - City: GREEN BAY
• Practice Address - State: WI
• Practice Address - Zip Code: 54301-3505
• Practice Address - Country: US
• Practice Address - Phone: 920-433-3640
• Practice Address - Fax: 920-433-3716
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-11-03
• Last Update Date: 2010-04-20

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207RC0000X	Allopathic & Osteopathic Physicians	Internal Medicine	Cardiovascular Disease	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MI	102929025	Medicaid
MI	104270274	Medicaid
MI	104284055	Medicaid
MI	104277810	Medicaid
MI	109521635	Medicaid
MI	105189687	Medicaid
MI	103318417	Medicaid
MI	104432532	Medicaid
MI	104692012	Medicaid
MI	102641408	Medicaid
MI	104277785	Medicaid
WI	P00456684	Other	RAILROAD MEDICARE
MI	N53040009	Medicare PIN
MI	N53040002	Medicare PIN
MI	104432532	Medicaid
MI	109521635	Medicaid
MI	N53040004	Medicare PIN
MI	N53040007	Medicare PIN
MI	102641408	Medicaid
MI	N53040005	Medicare PIN