Provider Demographics
NPI:1063894723
Name:SOUTHPORT CARDIOVASCULAR SURGEONS LLC
Entity type:Organization
Organization Name:SOUTHPORT CARDIOVASCULAR SURGEONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-843-4422
Mailing Address - Street 1:7137 236TH AVENUE
Mailing Address - Street 2:#103
Mailing Address - City:PADDOCK LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7137 236TH AVENUE
Practice Address - Street 2:#103
Practice Address - City:PADDOCK LAKE
Practice Address - State:WI
Practice Address - Zip Code:53168
Practice Address - Country:US
Practice Address - Phone:262-843-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38886208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty