1568643229 NPI number — OLD PUEBLO CARDIOLOGY PC

Table of content: (NPI 1568643229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568643229 NPI number — OLD PUEBLO CARDIOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLD PUEBLO CARDIOLOGY PC
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:
1568643229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64086
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85728-4086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-323-7277
Provider Business Mailing Address Fax Number:
520-881-1968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3955 E FORT LOWELL RD
Provider Second Line Business Practice Location Address:
SUITE 113
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85712-1041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-323-7277
Provider Business Practice Location Address Fax Number:
520-881-1968
Provider Enumeration Date:
11/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDBERG
Authorized Official First Name:
LEE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
520-323-7277

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: Z119329 . This is a "PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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