1215910633 NPI number — LUBBOCK CARDIOLOGY SPECIALISTS, PA

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 1215910633 NPI number — LUBBOCK CARDIOLOGY SPECIALISTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUBBOCK CARDIOLOGY SPECIALISTS, PA
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:
1215910633
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4802 N LOOP 289
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79416-3025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-788-0040
Provider Business Mailing Address Fax Number:
806-784-4202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4802 N LOOP 289
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79416-3025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-788-0040
Provider Business Practice Location Address Fax Number:
806-788-0015
Provider Enumeration Date:
11/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GHANDOUR
Authorized Official First Name:
MAIA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
806-788-0040

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: 085725201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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