Basic Information
| Provider Information | |||||||||
| NPI: | 1477585495 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOLOGY CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3006 N COUNTY ROAD 25A | ||||||||
| Address2: | STE 104 | ||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373353518 | ||||||||
| FaxNumber: | 9373351231 | ||||||||
| Practice Location | |||||||||
| Address1: | 3006 N COUNTY ROAD 25A | ||||||||
| Address2: | STE 104 | ||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373353518 | ||||||||
| FaxNumber: | 9373351231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 06/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | CZAJKA | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9373353518 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 021213700 | 01 | OH | BLACK LUNG | OTHER | 000000010016 | 01 | OH | ANTHEM PIN | OTHER | 5315621 | 01 | OH | AETNA | OTHER | 0885412 | 05 | OH | MEDICAID |