Basic Information
| Provider Information | |||||||||
| NPI: | 1487667549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERNDT | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 S WEBSTER AVE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204339621 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 S WEBSTER AVE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204339621 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 03/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 38744 | WI | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 770002360 | 01 | RAILROAD MEDICARE | OTHER | 32314300 | 05 | WI | MEDICAID |