Basic Information
| Provider Information | |||||||||
| NPI: | 1932404050 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA HEART PERFUSION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27341 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852857341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807770607 | ||||||||
| FaxNumber: | 4807771345 | ||||||||
| Practice Location | |||||||||
| Address1: | 5801 S MCCLINTOCK DR | ||||||||
| Address2: | 110 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852836002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807770607 | ||||||||
| FaxNumber: | 4807771345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2011 | ||||||||
| LastUpdateDate: | 01/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | MANDILE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4807770607 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CCP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 242T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Perfusionist |
No ID Information.