1124232202 NPI number — CARDIAC COMMUNITY CARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124232202 NPI number — CARDIAC COMMUNITY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDIAC COMMUNITY CARE
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:
1124232202
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2475 SAINT RAYMONDS AVE
Provider Second Line Business Mailing Address:
4TH FLOOR
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10461-3124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-239-5877
Provider Business Mailing Address Fax Number:
718-239-6957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2475 SAINT RAYMONDS AVE
Provider Second Line Business Practice Location Address:
4TH FLOOR
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10461-3124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-239-5877
Provider Business Practice Location Address Fax Number:
718-239-6957
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KLESTZICK
Authorized Official First Name:
HAL
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
SUPERVISOR
Authorized Official Telephone Number:
718-239-5877

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  195483 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01971168 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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