Basic Information
Provider Information | |||||||||
NPI: | 1598761538 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARDIOVASCULAR ASSOCIATES OF SOUTHEASTER PENNSYLVANIA PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 E LANCASTER AVE | ||||||||
Address2: | STE 356EAST | ||||||||
City: | WYNNEWOOD | ||||||||
State: | PA | ||||||||
PostalCode: | 190963450 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6106497625 | ||||||||
FaxNumber: | 6106493362 | ||||||||
Practice Location | |||||||||
Address1: | 100 E LANCASTER AVE | ||||||||
Address2: | STE 356EAST | ||||||||
City: | WYNNEWOOD | ||||||||
State: | PA | ||||||||
PostalCode: | 190963450 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6106497625 | ||||||||
FaxNumber: | 6106493362 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2005 | ||||||||
LastUpdateDate: | 02/08/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MABRY | ||||||||
AuthorizedOfficialFirstName: | MELISSA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6106497625 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 | 1007334230015 | 05 | PA |   | MEDICAID |