Basic Information
| Provider Information | |||||||||
| NPI: | 1730370156 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOVASCULAR CONSULTANTS MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15243 VANOWEN ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914053605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187825041 | ||||||||
| FaxNumber: | 8187824864 | ||||||||
| Practice Location | |||||||||
| Address1: | 14901 RINALDI ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183651339 | ||||||||
| FaxNumber: | 8188984301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 03/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | PATTERSON | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN / PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8187825041 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARDIOVASCULAR CONSULTANTS MEDICAL GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | W119 | 01 | CA | LEGACY NUMBER | OTHER | GR0026710 | 05 | CA | MEDICAID | GR0026711 | 05 | CA | MEDICAID |