1063811859 NPI number — HAVASU CARDIAC SURGERY PLLC

Table of content: DR. MICHAEL JOHN PALLADINO PHARM.D. (NPI 1376775288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063811859 NPI number — HAVASU CARDIAC SURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAVASU CARDIAC SURGERY PLLC
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:
1063811859
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 707
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86405-0707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-536-6453
Provider Business Mailing Address Fax Number:
888-491-7482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1741 MESQUITE AVE
Provider Second Line Business Practice Location Address:
STE. A200
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:
86403-5695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-536-6453
Provider Business Practice Location Address Fax Number:
888-491-7482
Provider Enumeration Date:
08/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KULSHRESTHA
Authorized Official First Name:
PANKAJ
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MEMBER
Authorized Official Telephone Number:
917-536-6453

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  36397 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P-1944708-5 . This is a "CORPORATION NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 016115 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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