Healthcare Provider Details

I. General information

NPI: 1205150026
Provider Name (Legal Business Name): SAN TAN CARDIOVASCULAR CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 05/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6740 S KINGS RANCH RD SUITE 103
GOLD CANYON AZ
85118-2925
US

IV. Provider business mailing address

6859 E REMBRANDT AVE SUITE 117
MESA AZ
85212-3628
US

V. Phone/Fax

Practice location:
  • Phone: 480-543-1525
  • Fax:
Mailing address:
  • Phone: 480-632-1577
  • Fax: 480-632-1574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number49056
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25431
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number40956
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3560
License Number StateAZ

VIII. Authorized Official

Name: DOTTIE RANKIN
Title or Position: OFFICE SUPERVISOR
Credential:
Phone: 480-632-1577