Provider Demographics
NPI:1508045113
Name:APPLETON CARDIAC & THORACIC SURGERY, S.C.
Entity Type:Organization
Organization Name:APPLETON CARDIAC & THORACIC SURGERY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:KERKHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-831-6135
Mailing Address - Street 1:1818 N MEADE ST
Mailing Address - Street 2:SUITE N347
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3454
Mailing Address - Country:US
Mailing Address - Phone:920-225-1449
Mailing Address - Fax:920-225-1425
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:SUITE N347
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-225-1449
Practice Address - Fax:920-225-1425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44645208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34279900Medicaid
WIG89528Medicare UPIN