Basic Information
Provider Information | |||||||||
NPI: | 1114026226 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARDIOLOGY ONE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KASSIR | ||||||||
AuthorizedOfficialFirstName: | MOHAMAD | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3304891386 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 0980710 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 9269611 | 01 | OH | OTHER MEDICARE | OTHER | 0980710 | 05 | OH |   | MEDICAID |