Basic Information
| Provider Information | |||||||||
| NPI: | 1003922287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 RETREAT AVE | ||||||||
| Address2: | SUITE 811 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061062563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605225712 | ||||||||
| FaxNumber: | 8605204270 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 RETREAT AVE | ||||||||
| Address2: | SUITE 811 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061062563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605225712 | ||||||||
| FaxNumber: | 8605204270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | KALLAL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8605225712 | ||||||||
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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 | 027525 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 004052098 | 05 | CT | MEDICAID | 604855 | 01 | TUFTS | OTHER | CM3450 | 01 | RAILROAD MEDICARE | OTHER |