Basic Information
| Provider Information | |||||||||
| NPI: | 1861457376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ISLAND CARDIAC CENTERS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1300 | ||||||||
| Address2: | MAIL CODE 60157 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968071300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003629772 | ||||||||
| FaxNumber: | 4256374646 | ||||||||
| Practice Location | |||||||||
| Address1: | 2230 LILIHA ST | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968171646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085850887 | ||||||||
| FaxNumber: | 8085854509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 03/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | PANG | ||||||||
| AuthorizedOfficialFirstName: | WENDELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8087827599 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471C1106X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Cardiac-Interventional Technology |
ID Information
| ID | Type | State | Issuer | Description | Z1629 | 01 | HI | MDX | OTHER | 0000235648 | 01 | HMSA 65C PLUS | OTHER | 50667801 | 05 | HI | MEDICAID | Z1629 | 01 | QUEENS MDX | OTHER | 0000235648 | 01 | HI | HMSA | OTHER | 0000235648 | 01 | MEDICAID HMSA QUEST | OTHER | 50667801 | 01 | MEDICAID CLASS | OTHER |