Basic Information
| Provider Information | |||||||||
| NPI: | 1205901022 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTA HEART CENTER LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 OAKSIDE LN | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301146417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707041955 | ||||||||
| FaxNumber: | 7707202388 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 OAKSIDE LN | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301146417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707041955 | ||||||||
| FaxNumber: | 7707202388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | ERNESTO | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CARDIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7707041955 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 050581 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | CK4374 | 01 | RAILROAD MEDICARE | OTHER |