# BLUE WATER THORACIC AND CARDIOVASCULAR SURGERY, PLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1336322528
- **Authorized official:** VERNON DENCKLAU DO (OWNER)
- **Authorized official phone:** (810) 989-6113

## Contact information

- **Practice address:** 1107 STONE ST, SUITE 1, PORT HURON, MI 48060-3569
- **Practice address phone:** (810) 989-6113
- **Practice address fax:** (810) 989-6117
- **Mailing address:** 1107 STONE ST, SUITE 1, PORT HURON, MI 48060-3569
- **Mailing address phone:** (810) 989-6113
- **Mailing address fax:** (810) 989-6117

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2086S0129X | Vascular Surgery Physician | 5101007542 | MI | — |
| 208G00000X | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician | 5101007542 | MI | Yes |

## Other

- **Enumeration date:** 12/11/2007
- **Last updated:** 08/11/2008