Basic Information
| Provider Information | |||||||||
| NPI: | 1003870809 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HILLCREST DIAGNOSTIC CARDIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7500 OLD OAK BLVD | ||||||||
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| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407776300 | ||||||||
| FaxNumber: | 4407772330 | ||||||||
| Practice Location | |||||||||
| Address1: | 6780 MAYFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403124399 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 02/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | BOTTI JR | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4409425400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0709853 | 05 | OH | MEDICAID |