1699750695 NPI number — CARDIAC DIAGNOSTIC CENTER LLC

Table of content: JUNGWEON VICTORIA PARK DMD (NPI 1962145516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699750695 NPI number — CARDIAC DIAGNOSTIC CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDIAC DIAGNOSTIC CENTER LLC
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:
1699750695
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10004 KENNERLY RD
Provider Second Line Business Mailing Address:
SUITE 281B
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63128-2141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-543-5270
Provider Business Mailing Address Fax Number:
314-543-5289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10004 KENNERLY RD
Provider Second Line Business Practice Location Address:
SUITE 281B
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-2141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-543-5270
Provider Business Practice Location Address Fax Number:
314-543-5289
Provider Enumeration Date:
12/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
CAT
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
314-543-5270

Provider Taxonomy Codes

  • Taxonomy code: 207UN0902X , with the licence number:  4560 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A11496 . This is a "MERCY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 8285720 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 511284 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 27454 . This is a "BLUE CHOICE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 157621 . This is a "BLUE CROSS/ BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: CJ7575 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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