NPIMap

Organization Active NPI

Blue Water Thoracic and Cardiovascular Surgery, PLC

  • Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
  • Port Huron, MI
National Provider Identifier
1336322528
Registry record updated Aug 11, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianTaxonomy code 208G00000X
License
5101007542 Issued in MI
Legal business name
BLUE WATER THORACIC AND CARDIOVASCULAR SURGERY, PLC
Practice address
1107 Stone St
Suite 1
Port Huron, MI 48060-3569
Phone
(810) 989-6113
Fax
(810) 989-6117
NPI assigned
Dec 11, 2007
Last updated
Aug 11, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 11, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Vernon Dencklau, DONPI 1821087453
Title
Owner
Phone
(810) 989-6113

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Vascular Surgery PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 2086S0129X 5101007542 MI
Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 208G00000X 5101007542 MI Primary

Addresses

Primary practice location

1107 Stone St
Suite 1
Port Huron, MI 48060-3569

Mailing address

1107 Stone St
Suite 1
Port Huron, MI 48060-3569
Phone (810) 989-6113

National Provider Directory

National Provider Directory

Locations

1117 Stone St
Ste 3
Port Huron, MI 48060
Phone (810) 989-6113

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1197331200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1218412800000",
    "number": "1336322528",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1107 STONE ST",
            "address_2": "SUITE 1",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "480603569",
            "telephone_number": "810-989-6113",
            "fax_number": "810-989-6117"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1107 STONE ST",
            "address_2": "SUITE 1",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "480603569",
            "telephone_number": "810-989-6113",
            "fax_number": "810-989-6117"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE WATER THORACIC AND CARDIOVASCULAR SURGERY, PLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-11",
        "last_updated": "2008-08-11",
        "status": "A",
        "authorized_official_last_name": "DENCKLAU",
        "authorized_official_first_name": "VERNON",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "810-989-6113",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "2086S0129X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Surgery, Vascular Surgery",
            "state": "MI",
            "license": "5101007542",
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": "MI",
            "license": "5101007542",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Port Huron, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 11, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.