Basic Information
Provider Information | |||||||||
NPI: | 1407830672 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BT HEART AND VASCULAR CENTER, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE HEART AND VASCULAR CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 110 EAST BLUE RIDGE ST | ||||||||
Address2: |   | ||||||||
City: | STUART | ||||||||
State: | VA | ||||||||
PostalCode: | 241711560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2766922540 | ||||||||
FaxNumber: | 3367197898 | ||||||||
Practice Location | |||||||||
Address1: | 110 EAST BLUE RIDGE ST. | ||||||||
Address2: |   | ||||||||
City: | STUART | ||||||||
State: | VA | ||||||||
PostalCode: | 241711560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2766922540 | ||||||||
FaxNumber: | 2766944206 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2005 | ||||||||
LastUpdateDate: | 10/22/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAGHIZADEH | ||||||||
AuthorizedOfficialFirstName: | BEHZAD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3367652500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 116217 | 01 | VA | AETNA | OTHER | 249989 | 01 | VA | SOUTHERN HEALTH | OTHER | DC09298 | 01 | VA | MEDICARE RR | OTHER |