Basic Information
| Provider Information | |||||||||
| NPI: | 1679599823 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED CARDIOVASCULAR DIAGNOSTICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21755 BROOKPARK RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441263200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407776305 | ||||||||
| FaxNumber: | 4407772330 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 ARCH ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302538195 | ||||||||
| FaxNumber: | 3302530853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAUMAN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3302538195 | ||||||||
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| 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 | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2050104 | 05 | OH | MEDICAID |