1649381724 NPI number — CARDIAC CARE ASSOCIATES PC

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 1649381724 NPI number — CARDIAC CARE ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDIAC CARE ASSOCIATES PC
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:
1649381724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3023 HAMAKER COURT
Provider Second Line Business Mailing Address:
SUITE #100
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-641-9161
Provider Business Mailing Address Fax Number:
703-641-0383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3023 HAMAKER CT
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-641-9161
Provider Business Practice Location Address Fax Number:
703-641-0383
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKS
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MD MANAGING PARTNER
Authorized Official Telephone Number:
703-641-9161

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DA1708 . This is a "RAIL ROAD MEDICARE ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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