Basic Information
| Provider Information | |||||||||
| NPI: | 1275874869 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BELLIN MEMORIAL HOSPITAL INC | ||||||||
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| OtherOrganizationName: | BELLIN HEALTH CARDIOVASCULAR AND THORACIC SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 S VANBUREN ST | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204330565 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 S VANBUREN ST | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204330565 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2013 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | STROOBANTS | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9204337864 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.