Basic Information
| Provider Information | |||||||||
| NPI: | 1356530901 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOLOGY ASSOCIATES OF VIDALIA, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1006 MOUNT VERNON RD | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304743029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125371221 | ||||||||
| FaxNumber: | 9125371012 | ||||||||
| Practice Location | |||||||||
| Address1: | 1006 MOUNT VERNON RD | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304743029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125371221 | ||||||||
| FaxNumber: | 9125371012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2007 | ||||||||
| LastUpdateDate: | 04/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | GILES | ||||||||
| AuthorizedOfficialFirstName: | ELAINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9125371221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 025159 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 000348169R | 05 | GA | MEDICAID | 252783403 | 01 | GA | TRICARE | OTHER | 060062628 | 01 | GA | RAILROAD MEDICARE | OTHER | 1104827369 | 01 | GA | NPI - INDIVIDUAL | OTHER |