1679502470 NPI number — HAVASU CARDIAC SURGERY 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 1679502470 NPI number — HAVASU CARDIAC SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAVASU CARDIAC SURGERY 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:
1679502470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3131 E CLARENDON AVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85016-7069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-253-9168
Provider Business Mailing Address Fax Number:
602-251-3126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 CIVIC CENTER LN
Provider Second Line Business Practice Location Address:
ATTN: HAVASU CARDIAC SURGERY
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-5607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-854-0090
Provider Business Practice Location Address Fax Number:
928-453-0671
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TIBI
Authorized Official First Name:
PIERRE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
602-253-9168

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117724 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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