Basic Information
| Provider Information | |||||||||
| NPI: | 1841362555 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-CITY PEDIACTRIC CARDIOLOGY P C | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRI-CITY PEDIACTRIC CARDIOLOGY P C | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3953 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376023953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236101099 | ||||||||
| FaxNumber: | 4236101166 | ||||||||
| Practice Location | |||||||||
| Address1: | 2312 KNOB CREEK RD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236101099 | ||||||||
| FaxNumber: | 4236101166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 04/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | MEHTA | ||||||||
| AuthorizedOfficialFirstName: | ASHOK | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 4236101099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 3722336 | 05 | TN | MEDICAID |