Basic Information
Provider Information | |||||||||
NPI: | 1861574840 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARDIAC DISEASE SPECIALISTS, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CARDIAC DISEASE SPECIALISTS, PC- NEWNAN | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 275 COLLIER RD NW | ||||||||
Address2: | STE 300 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303091704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043559815 | ||||||||
FaxNumber: | 4043500529 | ||||||||
Practice Location | |||||||||
Address1: | 58 HOSPITAL RD | ||||||||
Address2: | STE 106 | ||||||||
City: | NEWNAN | ||||||||
State: | GA | ||||||||
PostalCode: | 302631230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702530611 | ||||||||
FaxNumber: | 7705020521 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 11/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SACKS | ||||||||
AuthorizedOfficialFirstName: | HARVEY | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4043559815 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.