MEDICARE: PRIME CARDIOVASCULAR, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician

General Provider Information

NPI Number	:	1265062434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME CARDIOVASCULAR, LLC

Provider Business Mailing Address
First Line	:	3196 HIGHWAY 72 W
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38834-9303
Country	:	US
Telephone Number	:	662-284-9541
Fax Number	:	662-284-9543

Provider Business Practice Location Address
First Line	:	3196 HIGHWAY 72 W
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38834-9303
Country	:	US
Telephone Number	:	662-284-9541
Fax Number	:	662-284-9543

Authorized Official
Title or Position	:	MANAGER
Name	:	KARLA SHUMPERT
Credential	:	RN
Telephone Number	:	662-284-9541

Provider Enumeration Date	:	01/16/2020
Last Update Date	:	01/16/2020

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