Basic Information
| Provider Information | |||||||||
| NPI: | 1174637631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEART INSTITUTE OF EAST TEXAS P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 GASLIGHT BLVD | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759043133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366328787 | ||||||||
| FaxNumber: | 9366328832 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 GASLIGHT BLVD | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759043133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366328787 | ||||||||
| FaxNumber: | 9366328832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | BACHIREDDY | ||||||||
| AuthorizedOfficialFirstName: | RAVINDER | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9366328787 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207UN0901X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 084979601 | 05 | TX | MEDICAID |