Basic Information
| Provider Information | |||||||||
| NPI: | 1467640680 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIO OF CLARK & CHAMPAIGN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1911 E HIGH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455051227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373235064 | ||||||||
| FaxNumber: | 9373231407 | ||||||||
| Practice Location | |||||||||
| Address1: | 1141 N MONROE DR | ||||||||
| Address2: | |||||||||
| City: | XENIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453851619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373768336 | ||||||||
| FaxNumber: | 9373768352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2007 | ||||||||
| LastUpdateDate: | 01/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | GABBARD | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | KAE | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9373235064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARDIOLOGISTS OF CLARK & CHAMPAIGN COUNTIES INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
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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 | 0942412 | 05 | OH | MEDICAID | CM7602 | 01 | OH | RAILROAD MEDICARE | OTHER |