Basic Information
| Provider Information | |||||||||
| NPI: | 1770730764 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOTHORACIC SPECIALTIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10504 | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478010504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122348261 | ||||||||
| FaxNumber: | 8122348262 | ||||||||
| Practice Location | |||||||||
| Address1: | 1606 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478042706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122348261 | ||||||||
| FaxNumber: | 8122348262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2008 | ||||||||
| LastUpdateDate: | 08/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | MNAYARJI | ||||||||
| AuthorizedOfficialFirstName: | NABIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8122348261 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 01048818 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 200199020A | 05 | IN | MEDICAID |