1063687176 NPI number — HEART CLINIC OF LOUISVILLE, PSC

Table of content: (NPI 1063687176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063687176 NPI number — HEART CLINIC OF LOUISVILLE, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEART CLINIC OF LOUISVILLE, PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063687176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 N SHORE DR
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
JEFFERSONVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47130-3142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-218-9845
Provider Business Mailing Address Fax Number:
812-218-9850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 N SHORE DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
JEFFERSONVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47130-3142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-218-9845
Provider Business Practice Location Address Fax Number:
812-218-9850
Provider Enumeration Date:
04/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GIBSON
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
812-218-9845

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  01040911A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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