1407875636 NPI number — INDIANA CARDIAC & VASCULAR CONSULTANTS

Table of content: (NPI 1407875636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407875636 NPI number — INDIANA CARDIAC & VASCULAR CONSULTANTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA CARDIAC & VASCULAR CONSULTANTS
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:
6
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:
1407875636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 WILLOW ST STE C
Provider Second Line Business Mailing Address:
PO BOX 215
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47448-7013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-988-8116
Provider Business Mailing Address Fax Number:
812-988-8132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 WILLOW ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47448-7031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-988-8116
Provider Business Practice Location Address Fax Number:
812-988-8132
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOMARI
Authorized Official First Name:
HABIB
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
812-988-8116

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  01040158A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CN5946 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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