Provider Demographics
NPI:1659412401
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:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GERNDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-433-9621
Mailing Address - Street 1:720 SO VAN BUREN ST
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 1:720 S VAN BUREN ST
Practice Address - Street 2:SUITE 303
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3538
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:2007-02-12
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32897600Medicaid
WICG7604OtherRAILROAD MEDICARE
WI07690Medicare ID - Type Unspecified