Basic Information
| Provider Information | |||||||||
| NPI: | 1902140635 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOVASCULAR INSTITUTE OF MISSISSIPPI, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8548 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392848548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184244008 | ||||||||
| FaxNumber: | 3184246606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 CHADWICK DR | ||||||||
| Address2: | SUITE 256 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392043463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013761394 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | BAHRO | ||||||||
| AuthorizedOfficialFirstName: | ABDUL | ||||||||
| AuthorizedOfficialMiddleName: | GHAFOUR | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6013761394 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 16080 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.