1255464301 NPI number — CARDIOTHORACIC SURGERY GROUP, LLC

Table of content: ANNA GRACE BURNETTE PHD (NPI 1184246399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255464301 NPI number — CARDIOTHORACIC SURGERY GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDIOTHORACIC SURGERY GROUP, 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:
1255464301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 ARCH ST STE 407
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AKRON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44304-1433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-384-9001
Provider Business Mailing Address Fax Number:
330-384-9002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 ARCH ST STE 407
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AKRON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44304-1433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-384-9001
Provider Business Practice Location Address Fax Number:
330-384-9002
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ESPINAL
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
A
Authorized Official Title or Position:
TRIBE CHIEF
Authorized Official Telephone Number:
330-384-9001

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2459147 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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