Basic Information
| Provider Information | |||||||||
| NPI: | 1043241979 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH PHOENIX HEART CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848511 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900848511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028611168 | ||||||||
| FaxNumber: | 6026786723 | ||||||||
| Practice Location | |||||||||
| Address1: | 9250 N 3RD ST | ||||||||
| Address2: | SUITE 3010 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028611168 | ||||||||
| FaxNumber: | 6028611763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 11/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | BELANGER | ||||||||
| AuthorizedOfficialFirstName: | LEUEEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6028611168 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207UN0901X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 234761 | 05 | AZ | MEDICAID |