Healthcare Provider Details

I. General information

NPI: 1205076387
Provider Name (Legal Business Name): RUSSELLVILLE CARDIOLOGY CONSULTANTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S INGLEWOOD AVE
RUSSELLVILLE AR
72801-3353
US

IV. Provider business mailing address

106 S INGLEWOOD AVE
RUSSELLVILLE AR
72801-3353
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-4311
  • Fax: 479-968-4399
Mailing address:
  • Phone: 479-968-4311
  • Fax: 479-968-4399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberE5291
License Number StateAR

VIII. Authorized Official

Name: DR. DAI YUAN WANG
Title or Position: OWNER
Credential: MD
Phone: 479-968-4311