Basic Information
| Provider Information | |||||||||
| NPI: | 1255529590 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTSIDE CARDIOLOGY | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 N TENAYA WAY | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022558877 | ||||||||
| FaxNumber: | 7022558813 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 N TENAYA WAY | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022558877 | ||||||||
| FaxNumber: | 7022558813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2007 | ||||||||
| LastUpdateDate: | 06/22/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BILES | ||||||||
| AuthorizedOfficialFirstName: | MARIE | ||||||||
| AuthorizedOfficialMiddleName: | THERESE | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7022558877 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 7780 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 002019815 | 05 | NV | MEDICAID |