Basic Information
| Provider Information | |||||||||
| NPI: | 1063425486 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLUMBUS CARDIOVASCULAR CARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 BAPTIST BLVD | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397052011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622401412 | ||||||||
| FaxNumber: | 6622401949 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 BAPTIST BLVD | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397052011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622401412 | ||||||||
| FaxNumber: | 6622401949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOLAND | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6622401412 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00115039 | 05 | MS | MEDICAID |