Provider Demographics
NPI:1588664932
Name:STOCKMANN, PAUL T (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:STOCKMANN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:CHILDRENS HOSPITAL OF MICHIGAN
Mailing Address - Street 2:3901 BEAUBIEN BLVD
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-831-3220
Mailing Address - Fax:
Practice Address - Street 1:11123 PARKVIEW PLAZA DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-425-6100
Practice Address - Fax:260-425-6105
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2018-04-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI0574662086S0120X
IN01078636A2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3289600Medicaid
PS057466OtherCHAMPUS-CHAMPUS
MI329955410Medicaid
MI4115660Medicaid
MI020H277290OtherBLUE CROSS BLUE SHIELD MI
PS057466OtherCOMMERCIAL-COMMERCIAL NUMBER
MI1396817714OtherGROUP NPI
700H262310OtherBLUE CROSS-BLUE CROSS