Basic Information
| Provider Information | |||||||||
| NPI: | 1194380105 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERSONALIZED CARDIAC CARE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 ADDISON ST | ||||||||
| Address2: | |||||||||
| City: | WOODMERE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115982937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184406161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 E 79TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100750819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128791600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2019 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | AIVAZI | ||||||||
| AuthorizedOfficialFirstName: | ZAZA | ||||||||
| AuthorizedOfficialMiddleName: | JOSUHUA | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 7184544356 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 2491454 | 05 | NY | MEDICAID |