Basic Information
| Provider Information | |||||||||
| NPI: | 1992822563 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDDLETOWN CARDIOVASCULAR ASSOCIATES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROMED EQUIPMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 N BREIEL BLVD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450423807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137834222 | ||||||||
| FaxNumber: | 5132176037 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 N BREIEL BLVD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450423807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137834222 | ||||||||
| FaxNumber: | 5137834477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUPTA | ||||||||
| AuthorizedOfficialFirstName: | SANDEEP | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5137834222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207RS0012X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2734885 | 05 | OH | MEDICAID | DF8005 | 01 | OH | RAILROAD MEDICARE | OTHER | 613397200 | 01 | OH | DEPT OF LABOR-ENERGY DIVISION ACS | OTHER |