Basic Information
| Provider Information | |||||||||
| NPI: | 1356712848 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARDIOVASCULAR SOLUTIONS OF CENTRAL MS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 N PEARMAN AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387323502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887570838 | ||||||||
| FaxNumber: | 8887961835 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 N PEARMAN AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387323502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887570838 | ||||||||
| FaxNumber: | 8887961835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2015 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | FAKOREDE | ||||||||
| AuthorizedOfficialFirstName: | FOLUSO | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8887570838 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.