Basic Information
| Provider Information | |||||||||
| NPI: | 1790740447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MMH-COR ENTERPRISES IV LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARDIOVASCULAR DIAGNOSTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 VANDERBILT PARK DR | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282746000 | ||||||||
| FaxNumber: | 8282776350 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 VANDERBILT PARK DR | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282746000 | ||||||||
| FaxNumber: | 8282776350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 07/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | TALLEY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8282746000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 38785 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 470001688 | 05 | NC | MEDICAID |