Provider Demographics
NPI:1538306410
Name:GREEN BAY CARDIOTHORACIC & VASCULAR, LLC
Entity Type:Organization
Organization Name:GREEN BAY CARDIOTHORACIC & VASCULAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLEWINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-433-9621
Mailing Address - Street 1:720 S VANBUREN STREET
Mailing Address - Street 2:SUITE 303
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-433-9621
Mailing Address - Fax:920-433-0565
Practice Address - Street 1:1711 S STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3639
Practice Address - Country:US
Practice Address - Phone:920-433-9621
Practice Address - Fax:920-433-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659412401OtherMEDICARE NPI
WI32897600Medicaid