Basic Information
Provider Information
NPI: 1114026226
EntityType: 2
ReplacementNPI:  
OrganizationName: CARDIOLOGY ONE, INC
LastName:  
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Mailing Information
Address1: 4466 FULTON DR NW
Address2:  
City: CANTON
State: OH
PostalCode: 447182864
CountryCode: US
TelephoneNumber: 3304891386
FaxNumber: 3305260127
Practice Location
Address1: 4466 FULTON DR NW
Address2:  
City: CANTON
State: OH
PostalCode: 447182864
CountryCode: US
TelephoneNumber: 3304891386
FaxNumber: 3305260069
Other Information
ProviderEnumerationDate: 09/22/2006
LastUpdateDate: 10/20/2015
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: KASSIR
AuthorizedOfficialFirstName: MOHAMAD
AuthorizedOfficialMiddleName: S
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 3304891386
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RC0000X0980710OHY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease

ID Information
IDTypeStateIssuerDescription
926961101OHOTHER MEDICAREOTHER
098071005OH MEDICAID


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