1104831775 NPI number — MOUNTAIN HEART CENTER, PSC

Table of content: (NPI 1104831775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104831775 NPI number — MOUNTAIN HEART CENTER, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN HEART CENTER, PSC
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:
1104831775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 767
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITESBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41858-0767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-633-5520
Provider Business Mailing Address Fax Number:
606-633-5515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 JENKINS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITESBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41858-7189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-633-5520
Provider Business Practice Location Address Fax Number:
606-633-5515
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHANDRASHEKAR
Authorized Official First Name:
PADUBIDRI
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
606-633-5520

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  29202 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 65929432 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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