Basic Information
| Provider Information | |||||||||
| NPI: | 1306845334 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINICAL CARDIOLOGY SPECIALISTS, INC. | ||||||||
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| OtherOrganizationName: | CLINICAL CARDIOVASCULAR SPECIALISTS, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 OLENTANGY RIVER RD | ||||||||
| Address2: | SUITE 6300 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432143937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144597676 | ||||||||
| FaxNumber: | 6144597681 | ||||||||
| Practice Location | |||||||||
| Address1: | 3525 OLENTANGY RIVER RD | ||||||||
| Address2: | SUITE 6300 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432143937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144597676 | ||||||||
| FaxNumber: | 6144597681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| AuthorizedOfficialLastName: | TIMKO | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 6144597676 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35-05-6053 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | CM1574 | 01 | OH | RAILROAD MEDICARE | OTHER | 0792969 | 05 | OH | MEDICAID |