Basic Information
| Provider Information | |||||||||
| NPI: | 1407855265 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL COAST CARDIOLOGY A MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CENTRAL COAST CARDIOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 230 SAN JOSE ST | ||||||||
| Address2: | |||||||||
| City: | SALINAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939013901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317582100 | ||||||||
| FaxNumber: | 8317580311 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 LOWER RAGSDALE DR | ||||||||
| Address2: | #102 | ||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939405817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316493375 | ||||||||
| FaxNumber: | 8312335182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 08/02/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALBERT | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8317582100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRAL COAST CARDIOLOGY A MEDICAL CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | GR0059321 | 05 | CA | MEDICAID | ZZZ55762Z | 01 | CA | BLUE SHIELD FOR MONTEREY CD | OTHER |