Basic Information
| Provider Information | |||||||||
| NPI: | 1609180066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOVASCULAR GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BARTOL AVE | ||||||||
| Address2: | STE 10 | ||||||||
| City: | RIDLEY PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190782214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105210150 | ||||||||
| FaxNumber: | 6105216493 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 PLUSH MILL RD | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190866040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105210150 | ||||||||
| FaxNumber: | 6105216493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2010 | ||||||||
| LastUpdateDate: | 07/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | RUBY | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 6105210150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARDIOVASCULAR GROUP LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 |
No ID Information.