Basic Information
| Provider Information | |||||||||
| NPI: | 1114355120 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUNTSVILLE CARDIOVASCULAR CLINIC, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 WHITESBURG DR SE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358021676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568801050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4601 WHITESBURG DR SE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358021676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568801050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2013 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | HEDRICK | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2568801050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1-109897 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1-109897 | 01 | AL | CRNP COLLABORATIVE PRACTICE LICENSE | OTHER |